1205841723 NPI number — PATTI ANN BALESTRIERI PA-C

Table of content: PATTI ANN BALESTRIERI PA-C (NPI 1205841723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205841723 NPI number — PATTI ANN BALESTRIERI PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALESTRIERI
Provider First Name:
PATTI
Provider Middle Name:
ANN
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:
MCFARLIN
Provider Other First Name:
PATTI
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205841723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
323 S 18TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STURGEON BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54235-1401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-746-0510
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
323 S 18TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STURGEON BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54235-1401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-746-0510
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2006

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: 363A00000X , with the licence number:  945023 , 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: 42964500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com