1780669523 NPI number — WANDA G SHIOTSUKA OT

Table of content: WANDA G SHIOTSUKA OT (NPI 1780669523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780669523 NPI number — WANDA G SHIOTSUKA OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIOTSUKA
Provider First Name:
WANDA
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
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:
1780669523
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:
PO BOX 612260
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-325-2776
Provider Business Mailing Address Fax Number:
408-945-4011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10565 BRUNSWICK ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRASS VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95945-9053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-273-4152
Provider Business Practice Location Address Fax Number:
530-273-4153
Provider Enumeration Date:
12/14/2005

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: 225X00000X , with the licence number:  OT 5422 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225XH1200X , with the licence number: OT 5422 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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