1316040298 NPI number — GLORIA CRESENCIA B. ABACAN

Table of content: GLORIA CRESENCIA B. ABACAN (NPI 1316040298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316040298 NPI number — GLORIA CRESENCIA B. ABACAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ABACAN
Provider First Name:
GLORIA
Provider Middle Name:
CRESENCIA B.
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:
ABACAN
Provider Other First Name:
GLORIA
Provider Other Middle Name:
C. BALDEMOR
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1316040298
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
820 MEMORIAL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROSSER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99350-2504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-786-2010
Provider Business Mailing Address Fax Number:
509-788-1794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
820 MEMORIAL ST STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROSSER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99350-2504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-786-2010
Provider Business Practice Location Address Fax Number:
509-788-1794
Provider Enumeration Date:
09/06/2006

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: 207R00000X , with the licence number:  MD00039221 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1306897681 . This is a "NPI PROSSER MEMORIAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2035AB . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 911019392 . This is a "COMMERCIAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8265142 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 156636 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 22855 . This is a "GROUP HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8265142 . This is a "CHPW" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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