1063872604 NPI number — ERIN BASS

Table of content: ERIN BASS (NPI 1063872604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063872604 NPI number — ERIN BASS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASS
Provider First Name:
ERIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ABROMEIT
Provider Other First Name:
ERIN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063872604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDPOINT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83864-0908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
810 N. SIXTH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-5396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-265-2242
Provider Business Practice Location Address Fax Number:
208-265-8214
Provider Enumeration Date:
02/24/2016

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: 363L00000X , with the licence number:  NP-1712A , 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: NP-1712A . This is a "ID LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com