1245494517 NPI number — EXAGEN INC.

Table of content: (NPI 1245494517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245494517 NPI number — EXAGEN INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXAGEN INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EXAGEN DIAGNOSTICS
Provider Other Organization Name Type Code:
4
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:
1245494517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 27561
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87125-7561
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-452-1522
Provider Business Mailing Address Fax Number:
760-479-6486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1261 LIBERTY WAY STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92081-8356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-452-1522
Provider Business Practice Location Address Fax Number:
760-479-6486
Provider Enumeration Date:
07/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KILLINGS
Authorized Official First Name:
NIKKI
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
760-539-3031

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  CLF 00334804 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8369 . This is a "NEW YORK STATE DEPARTMENT OF HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ555113Y . This is a "BLUE SHIELD OF CALIFORNIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1484 . This is a "MARYLAND DEPT OF HEALTH" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: LCO00685 . This is a "RHODE ISLAND DEPT OF HEALTH" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 31066 . This is a "PENNSYLVANIA DEPT OF HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 05D1075048 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: CDF-00334804 . This is a "CLINICAL AND PUBLIC HEALTH LABORATORY LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 013701400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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