1720242068 NPI number — WANDA DEL CARMEN JIRAU-ROSALY M.D

Table of content: WANDA DEL CARMEN JIRAU-ROSALY M.D (NPI 1720242068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720242068 NPI number — WANDA DEL CARMEN JIRAU-ROSALY M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JIRAU-ROSALY
Provider First Name:
WANDA
Provider Middle Name:
DEL CARMEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
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:
1720242068
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1499 WALTON WAY STE 1400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30901-2603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-724-6100
Provider Business Mailing Address Fax Number:
706-721-7016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MADIGAN ARMY MEDICAL CTR
Provider Second Line Business Practice Location Address:
9040 REID ST.
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98431-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-968-2252
Provider Business Practice Location Address Fax Number:
253-968-3278
Provider Enumeration Date:
07/16/2008

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: 207Q00000X , with the licence number:  01059043A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QG0300X , with the licence number: 077153 , 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)





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