1336464783 NPI number — MRS. MARILYN MARTIN PETRO WHNP-RX AUTH

Table of content: MRS. MARILYN MARTIN PETRO WHNP-RX AUTH (NPI 1336464783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336464783 NPI number — MRS. MARILYN MARTIN PETRO WHNP-RX AUTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRO
Provider First Name:
MARILYN
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
WHNP-RX AUTH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETRO
Provider Other First Name:
MARTI
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1336464783
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1141 KELLER PKWY
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
KELLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76248-1627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-741-2601
Provider Business Mailing Address Fax Number:
817-745-2601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1141 KELLER PKWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
KELLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76248-1627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-741-2601
Provider Business Practice Location Address Fax Number:
817-745-2601
Provider Enumeration Date:
03/29/2010

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: 363LX0001X , with the licence number:  685722 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1578768701 . This is a "GROUP NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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