1891735403 NPI number — ROBIN A INGRAHAM PT

Table of content: ROBIN A INGRAHAM PT (NPI 1891735403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891735403 NPI number — ROBIN A INGRAHAM PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
INGRAHAM
Provider First Name:
ROBIN
Provider Middle Name:
A
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:
1891735403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1519 132ND ST SE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98208-7203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-330-0633
Provider Business Mailing Address Fax Number:
425-338-9637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 W STANLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANITE FALLS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98252-8631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-691-4835
Provider Business Practice Location Address Fax Number:
360-691-2545
Provider Enumeration Date:
06/08/2006

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: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8336463 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 911745305-98252-B003 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0128226 . This is a "LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7491IN . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 5085695 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: Q4WYR1 . This is a "EMPIRE BC,BS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8928858 . This is a "L&I CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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