1629130406 NPI number — MARA DANIELLE PACYGA MSPT

Table of content: MARA DANIELLE PACYGA MSPT (NPI 1629130406)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629130406 NPI number — MARA DANIELLE PACYGA MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PACYGA
Provider First Name:
MARA
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
F

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:
1629130406
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
280 ZEREX ST
Provider Second Line Business Mailing Address:
POB 1345
Provider Business Mailing Address City Name:
FRASER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80442-1345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-726-8503
Provider Business Mailing Address Fax Number:
970-726-8941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 ZEREX ST.
Provider Second Line Business Practice Location Address:
POB 1345
Provider Business Practice Location Address City Name:
FRASER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80442-1345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-726-8503
Provider Business Practice Location Address Fax Number:
970-726-8941
Provider Enumeration Date:
12/15/2006

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: 2251X0800X , with the licence number:  7663 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7663 . This is a "STATE PT LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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