1801051826 NPI number — MRS. JENNIFER RACHAEL SURGENER FNP

Table of content: MRS. JENNIFER RACHAEL SURGENER FNP (NPI 1801051826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801051826 NPI number — MRS. JENNIFER RACHAEL SURGENER FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SURGENER
Provider First Name:
JENNIFER
Provider Middle Name:
RACHAEL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOSS
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
RACHAEL
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:
1801051826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14642 NEWPORT AVE
Provider Second Line Business Mailing Address:
SUITE #200
Provider Business Mailing Address City Name:
TUSTIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92780-6057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-669-4466
Provider Business Mailing Address Fax Number:
714-669-4088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14642 NEWPORT AVE
Provider Second Line Business Practice Location Address:
SUITE #200
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780-6057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-669-4466
Provider Business Practice Location Address Fax Number:
714-669-4088
Provider Enumeration Date:
07/21/2008

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: 363LF0000X , with the licence number:  15194 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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