1740315092 NPI number — KRISTA MICHELLE MORGAN BRANCH PT

Table of content: KRISTA MICHELLE MORGAN BRANCH PT (NPI 1740315092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740315092 NPI number — KRISTA MICHELLE MORGAN BRANCH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRANCH
Provider First Name:
KRISTA
Provider Middle Name:
MICHELLE MORGAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1740315092
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7215 W BRIDLE TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-8025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-226-1789
Provider Business Mailing Address Fax Number:
928-779-0557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 E CHERRY AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86001-4699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-779-0446
Provider Business Practice Location Address Fax Number:
928-779-0557
Provider Enumeration Date:
02/23/2007

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: 225100000X , with the licence number:  PTL-8335 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2251P0200X , with the licence number: 4115 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 474924 . This is a "AHCCCS PROVIDER ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".