1982776795 NPI number — DR. AUDREY M. PAYNE MD

Table of content: DR. AUDREY M. PAYNE MD (NPI 1982776795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982776795 NPI number — DR. AUDREY M. PAYNE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAYNE
Provider First Name:
AUDREY
Provider Middle Name:
M.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VAN HISE
Provider Other First Name:
AUDREY
Provider Other Middle Name:
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:
1982776795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2626 N CALIFORNIA ST STE G
Provider Second Line Business Mailing Address:
P.O. BOX 4057
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95204-5500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-464-9846
Provider Business Mailing Address Fax Number:
209-464-4082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2626 N CALIFORNIA ST STE G
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95204-5500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-464-9846
Provider Business Practice Location Address Fax Number:
209-464-4082
Provider Enumeration Date:
11/15/2006

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: 207L00000X , with the licence number:  A87036 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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