1184837189 NPI number — TASHA R WHITCOMB

Table of content: TASHA R WHITCOMB (NPI 1184837189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184837189 NPI number — TASHA R WHITCOMB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITCOMB
Provider First Name:
TASHA
Provider Middle Name:
R
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:
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:
1184837189
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 MAPLE GROVE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEVENS POINT
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54482-9284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-370-2094
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4605 VALDRES SPRINGS CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54476-4189
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-393-0419
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/07/2007

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: 225200000X , with the licence number:  1351-019 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 36122600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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