1033205042 NPI number — KATHLEEN S BOCHNOWSKI PT

Table of content: KATHLEEN S BOCHNOWSKI PT (NPI 1033205042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033205042 NPI number — KATHLEEN S BOCHNOWSKI PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOCHNOWSKI
Provider First Name:
KATHLEEN
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033205042
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 681927
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARK CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84068-1927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-575-0345
Provider Business Mailing Address Fax Number:
435-575-0346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6030 MARKET ST
Provider Second Line Business Practice Location Address:
SUITE 135
Provider Business Practice Location Address City Name:
PARK CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84098-7927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-575-0345
Provider Business Practice Location Address Fax Number:
435-575-0346
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5111951-2401 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 529455447001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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