1346209343 NPI number — DEBRA ANN GUTZMAN NNP

Table of content: DEBRA ANN GUTZMAN NNP (NPI 1346209343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346209343 NPI number — DEBRA ANN GUTZMAN NNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUTZMAN
Provider First Name:
DEBRA
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAY
Provider Other First Name:
DEBRA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346209343
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:
6919 BLACK DUCK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINO LAKES
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55014-1319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-653-1078
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1655 BEAM AVE
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
MAPLEWOOD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55109-1163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-232-7031
Provider Business Practice Location Address Fax Number:
651-232-7826
Provider Enumeration Date:
03/20/2006

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: 363LN0000X , with the licence number:  R104719-8 , 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: 43886400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com