1851316871 NPI number — BRENDA K BALTHAZOR PA

Table of content: BRENDA K BALTHAZOR PA (NPI 1851316871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851316871 NPI number — BRENDA K BALTHAZOR PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALTHAZOR
Provider First Name:
BRENDA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1851316871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
512 S 28TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUSAU
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54401-4147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-847-2021
Provider Business Mailing Address Fax Number:
715-847-2325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
512 S 28TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUSAU
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54401-4147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-847-2021
Provider Business Practice Location Address Fax Number:
715-847-2325
Provider Enumeration Date:
07/12/2006

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: 363AM0700X , with the licence number:  186923 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 42871300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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