1114007382 NPI number — MRS. ILYNE SANDAS MALP

Table of content: MRS. ILYNE SANDAS MALP (NPI 1114007382)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114007382 NPI number — MRS. ILYNE SANDAS MALP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANDAS
Provider First Name:
ILYNE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MALP
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:
1114007382
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8141 MAPLEWOOD TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANHASSEN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55317-9661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-941-2889
Provider Business Mailing Address Fax Number:
952-401-9326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9531 W 78TH ST
Provider Second Line Business Practice Location Address:
125
Provider Business Practice Location Address City Name:
EDEN PRAIRIE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55344-3810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-941-2889
Provider Business Practice Location Address Fax Number:
952-402-9326
Provider Enumeration Date:
10/16/2006

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: 101YM0800X , with the licence number:  LP3248 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 22G21SA . This is a "BLUE CROSS BLUE SHIELD OF" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 62-90595 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1045950000 , issued by the state of ( FM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 937020 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 81860 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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