1013153147 NPI number — DONNA MARIE PROKOP-FETTIG P.A.-C

Table of content: DONNA MARIE PROKOP-FETTIG P.A.-C (NPI 1013153147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013153147 NPI number — DONNA MARIE PROKOP-FETTIG P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROKOP-FETTIG
Provider First Name:
DONNA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
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:
1013153147
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 268945
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73126-8945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-388-1861
Provider Business Mailing Address Fax Number:
512-388-0373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 SAM BASS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROUND ROCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78681-4137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-388-1861
Provider Business Practice Location Address Fax Number:
512-388-0373
Provider Enumeration Date:
12/18/2008

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: 363AM0700X , with the licence number:  PA06103 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2028235-02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2028235-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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