1053898833 NPI number — SPORTSMEDICINE OUTREACH SPECIALIST

Table of content: (NPI 1053898833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053898833 NPI number — SPORTSMEDICINE OUTREACH SPECIALIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTSMEDICINE OUTREACH SPECIALIST
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1053898833
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
835 W WARNER RD
Provider Second Line Business Mailing Address:
STE 101-448
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85233-7269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-980-8206
Provider Business Mailing Address Fax Number:
480-281-5224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
835 W WARNER RD
Provider Second Line Business Practice Location Address:
STE 101-448
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85233-7269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-689-9588
Provider Business Practice Location Address Fax Number:
480-281-5224
Provider Enumeration Date:
07/24/2018

Additional Information

Authorized Official

Authorized Official Last Name:
OVERLIN
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
DEAN
Authorized Official Title or Position:
PHYSICIAN ASSISTANT
Authorized Official Telephone Number:
602-689-9588

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  3233 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com