1235469446 NPI number — MALYNDA LYNN TUSHBANT PA-C

Table of content: MALYNDA LYNN TUSHBANT PA-C (NPI 1235469446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235469446 NPI number — MALYNDA LYNN TUSHBANT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUSHBANT
Provider First Name:
MALYNDA
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:
CALKINS
Provider Other First Name:
MALYNDA
Provider Other Middle Name:
LYNN
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:
1235469446
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
580 W 5TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89503-4407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-786-4673
Provider Business Mailing Address Fax Number:
775-348-2889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
580 W 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89503-4407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-786-4673
Provider Business Practice Location Address Fax Number:
775-348-2889
Provider Enumeration Date:
01/11/2010

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:  PA0200 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PA0200 . This is a "LICENSE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: CZ375Z . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: PA1737 . This is a "LICENSE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".