1013290410 NPI number — CAROLYN RENEE WAGNER VON HOFF P.A.C.

Table of content: CAROLYN RENEE WAGNER VON HOFF P.A.C. (NPI 1013290410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013290410 NPI number — CAROLYN RENEE WAGNER VON HOFF P.A.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER VON HOFF
Provider First Name:
CAROLYN
Provider Middle Name:
RENEE
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:
DECARLI
Provider Other First Name:
CAROLYN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1013290410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18444 N 25TH AVE STE 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85023-1266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-974-2673
Provider Business Mailing Address Fax Number:
866-939-2673

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3591 S MERCY RD STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85297-2240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-974-2673
Provider Business Practice Location Address Fax Number:
866-939-2673
Provider Enumeration Date:
09/21/2011

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: 363A00000X , with the licence number:  4954 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4954 . This is a "ARIZONA BOARD OF PHYSICIAN ASSISTANTS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com