1922168293 NPI number — MS. YVONNE M MCCALL PA

Table of content: MS. YVONNE M MCCALL PA (NPI 1922168293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922168293 NPI number — MS. YVONNE M MCCALL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCALL
Provider First Name:
YVONNE
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
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:
DRABEK
Provider Other First Name:
YVONNE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922168293
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 W. GARDEN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61605-3531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-680-7600
Provider Business Mailing Address Fax Number:
309-676-5506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 W. GARDEN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61605-3531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-680-7600
Provider Business Practice Location Address Fax Number:
309-680-7637
Provider Enumeration Date:
12/09/2006

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:  5160373-1206 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5160373-1206 . This is a "STATE LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 5160373-8906 . This is a "DOPL CONTROLLED SUBSTANCE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 085-003423 . This is a "STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1054008 . This is a "NCCPA BOARD CERTIFICATION" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: PRA07224 . This is a "MOLINA HEALTHCARE OF UT" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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