1043364722 NPI number — PEGGY O SHORTT ARNP

Table of content: PEGGY O SHORTT ARNP (NPI 1043364722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043364722 NPI number — PEGGY O SHORTT ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHORTT
Provider First Name:
PEGGY
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1043364722
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5127
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98206-5127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-258-3900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3901 HOYT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98201-4918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-339-5412
Provider Business Practice Location Address Fax Number:
425-259-1164
Provider Enumeration Date:
01/22/2007

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: 363L00000X , with the licence number:  AP30005632 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1042641 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9641127 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0202016 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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