1568636306 NPI number — ASHLEY SUZAM NORDSTROM PA-C

Table of content: ASHLEY SUZAM NORDSTROM PA-C (NPI 1568636306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568636306 NPI number — ASHLEY SUZAM NORDSTROM PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NORDSTROM
Provider First Name:
ASHLEY
Provider Middle Name:
SUZAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAVENEL
Provider Other First Name:
ASHLEY
Provider Other Middle Name:
SUZAM
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568636306
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
898 COLLEGE ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MONTICELLO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31064-1258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-468-0988
Provider Business Mailing Address Fax Number:
706-468-6631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
898 COLLEGE ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31064-1258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-468-0988
Provider Business Practice Location Address Fax Number:
706-468-6631
Provider Enumeration Date:
04/14/2008

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:  005296 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003141276A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com