1043889470 NPI number — JAYLA FLAUM PA-C

Table of content: JAYLA FLAUM PA-C (NPI 1043889470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043889470 NPI number — JAYLA FLAUM PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLAUM
Provider First Name:
JAYLA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-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:
1043889470
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 BROWN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31220-6754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-272-7589
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
987 PARALLEL DR STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEPORT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95453-5708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-262-5088
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/21/2021

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:  0010-11360 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 64913 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0010-11360 . This is a "NORTH CAROLINA STATE MEDICAL BOARD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 64913 . This is a "CALIFORNIA STATE MEDICAL BOARD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 10690 . This is a "GEORGIA COMPOSITE MEDICAL BOARD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: NONE . This is a "NONE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com