1699202978 NPI number — MALLORY TRANAEE GOTHE MS, PLPC

Table of content: MALLORY TRANAEE GOTHE MS, PLPC (NPI 1699202978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699202978 NPI number — MALLORY TRANAEE GOTHE MS, PLPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOTHE
Provider First Name:
MALLORY
Provider Middle Name:
TRANAEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, PLPC
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:
1699202978
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. Box 627
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
Maurice
Provider Business Mailing Address State Name:
Louisiana
Provider Business Mailing Address Postal Code:
70555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
3377037233
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1602 W. Pinhook Rd. St. 100A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
Lafayette
Provider Business Practice Location Address State Name:
Louisiana
Provider Business Practice Location Address Postal Code:
70508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
3379812180
Provider Business Practice Location Address Fax Number:
3379812391
Provider Enumeration Date:
05/17/2017

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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