1477585222 NPI number — JESSICA A NORTON PAC

Table of content: JESSICA A NORTON PAC (NPI 1477585222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477585222 NPI number — JESSICA A NORTON PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NORTON
Provider First Name:
JESSICA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUTZEN
Provider Other First Name:
JESSICA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477585222
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19021 FREEPORT ST NW
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ELK RIVER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55330-1278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-645-3313
Provider Business Mailing Address Fax Number:
763-432-7544

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19021 FREEPORT ST NW
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ELK RIVER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55330-1278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-645-3313
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/06/2006

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: 363A00000X , with the licence number:  9673 , 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: 141285 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 964851028877 . This is a "P ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0120726 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 156615600 . This is a "NEW MA PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00232858 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 381K3RU . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 970002200 . This is a "METRAHEALTH MPIN" identifier . This identifiers is of the category "OTHER".




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