1154518900 NPI number — MS. CAROL SUE CDEBACA PA-C

Table of content: MS. CAROL SUE CDEBACA PA-C (NPI 1154518900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154518900 NPI number — MS. CAROL SUE CDEBACA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CDEBACA
Provider First Name:
CAROL
Provider Middle Name:
SUE
Provider Name Prefix Text:
MS.
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:
1154518900
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2331 FRANKLIN RD SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24014-1111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-725-1226
Provider Business Mailing Address Fax Number:
540-857-5306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 KNOTBREAK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24153-5404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-444-4020
Provider Business Practice Location Address Fax Number:
540-857-5306
Provider Enumeration Date:
09/26/2007

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:  0110002628 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1154518900 . This is a "SOUTHERN HEALTH/CARENET/CARELINK/COVENTRY" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P01464014 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1154518900 . This is a "IN TOTAL" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1154518900 . This is a "MEDICAID QMB" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1154518900 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1154518900 . This is a "CCC VIRGINIA PREMIER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1154518900 . This is a "OPTIMA HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 540506332115 . This is a "TRICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1154518900 . This is a "HUMANA MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1154518900 . This is a "ANTHEM MEDIGAP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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