1831634005 NPI number — MARISA VANG

Table of content: DEBRA HOPE FEDERER MD (NPI 1144241357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831634005 NPI number — MARISA VANG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANG
Provider First Name:
MARISA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VANG
Provider Other First Name:
MARISA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNMT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1831634005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5936 BEARD AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN CENTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55429-2630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-402-1013
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5936 BEARD AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN CENTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55429-2630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-402-1013
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/27/2016

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: 225700000X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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