1114178837 NPI number — KIRSTEN LYNN SHIPWAY PA-C

Table of content: KIRSTEN LYNN SHIPWAY PA-C (NPI 1114178837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114178837 NPI number — KIRSTEN LYNN SHIPWAY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIPWAY
Provider First Name:
KIRSTEN
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1114178837
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1871 W ORANGE GROVE RD STE 135
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85704-1289
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-382-3050
Provider Business Mailing Address Fax Number:
520-382-3055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1871 W ORANGE GROVE RD STE 135
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85704-1289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-382-3050
Provider Business Practice Location Address Fax Number:
520-382-3055
Provider Enumeration Date:
10/01/2008

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: 363AS0400X , with the licence number:  4286 , 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)