1548735681 NPI number — MR. JASON WADE KNISLEY CMT

Table of content: DR. ELIE HARMOUCHE M.D (NPI 1700204229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548735681 NPI number — MR. JASON WADE KNISLEY CMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KNISLEY
Provider First Name:
JASON
Provider Middle Name:
WADE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CMT
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:
1548735681
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
855 EL CAMINO REAL STE 13A-251
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALO ALTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94301-2305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-564-3375
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
855 EL CAMINO REAL STE 13A-251
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALO ALTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94301-2305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-564-3375
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
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Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  2722 , 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)