1417979832 NPI number — MRS. MICAH LEA MONK R.D., L.D.

Table of content: MRS. MICAH LEA MONK R.D., L.D. (NPI 1417979832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417979832 NPI number — MRS. MICAH LEA MONK R.D., L.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONK
Provider First Name:
MICAH
Provider Middle Name:
LEA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
R.D., L.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WING
Provider Other First Name:
MICAH
Provider Other Middle Name:
LEA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417979832
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:
2036 PARKER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMARILLO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79109-2018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-206-4772
Provider Business Mailing Address Fax Number:
806-354-1679

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NORTHWEST TEXAS HEALTHCARE SYSTEM
Provider Second Line Business Practice Location Address:
1501 SOUTH COULTER
Provider Business Practice Location Address City Name:
AMARILLO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-354-1720
Provider Business Practice Location Address Fax Number:
806-354-1679
Provider Enumeration Date:
07/24/2006

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: 133V00000X , with the licence number:  923397 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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