1548308240 NPI number — VICTORIA OZERAN PA

Table of content: VICTORIA OZERAN PA (NPI 1548308240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548308240 NPI number — VICTORIA OZERAN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OZERAN
Provider First Name:
VICTORIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1548308240
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 189
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKSTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99403-0189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-758-5511
Provider Business Mailing Address Fax Number:
509-758-3700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1119 HIGHLAND AVE STE 11
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99403-2836
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-758-4450
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/02/2007

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: 363A00000X , with the licence number:  PA-409 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8362154 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806533100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10142845 . This is a "REGENCE OF ID URGENT CARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 10142846 . This is a "REGENCE OF IDAHO ER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: HBMZ5 . This is a "BLUE CROSS OF IDAHO IND" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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