1447227293 NPI number — TROY A LANDES PA

Table of content: TROY A LANDES PA (NPI 1447227293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447227293 NPI number — TROY A LANDES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANDES
Provider First Name:
TROY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1447227293
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:
211 16TH AVE N
Provider Second Line Business Mailing Address:
PO BOX 9
Provider Business Mailing Address City Name:
NAMPA
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83687-4058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-461-7149
Provider Business Mailing Address Fax Number:
208-467-3391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARSING
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-896-4159
Provider Business Practice Location Address Fax Number:
208-896-4917
Provider Enumeration Date:
03/01/2006

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: 363A00000X , with the licence number:  MA050718 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 25-1716306 . This is a "INTERGROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50064072 . This is a "CAPITAL BLUECROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 120420414 . This is a "DEPT OF LABOR" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 25-1716306 . This is a "INFORMED" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 498815 . This is a "HEALTH AMERICA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007307260034 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: MA050718 . This is a "LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 25-1716306 . This is a "SOUTH CENTRAL PREFERRED" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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