1366481681 NPI number — MR. BRYCE ALLEN YASENAK DPT

Table of content: MR. BRYCE ALLEN YASENAK DPT (NPI 1366481681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366481681 NPI number — MR. BRYCE ALLEN YASENAK DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YASENAK
Provider First Name:
BRYCE
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

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:
1366481681
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
336 FAIRGROUNDS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMILTON
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59840-3126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-375-0980
Provider Business Mailing Address Fax Number:
406-375-9938

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
502 N MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 900
Provider Business Practice Location Address City Name:
DARBY
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-821-2021
Provider Business Practice Location Address Fax Number:
406-821-1120
Provider Enumeration Date:
06/05/2006

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: 225100000X , with the licence number:  1759 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3401224 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 626010 . This is a "BCBS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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