1053053934 NPI number — EDWARD DEHERRERA SUDPT

Table of content: EDWARD DEHERRERA SUDPT (NPI 1053053934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053053934 NPI number — EDWARD DEHERRERA SUDPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEHERRERA
Provider First Name:
EDWARD
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SUDPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEHERRERA
Provider Other First Name:
EDDY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1053053934
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
140 S ARTHUR ST STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99202-2220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-532-8855
Provider Business Mailing Address Fax Number:
509-532-8844

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 S ARTHUR STREET, SUITE 400
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99202-9920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-532-8855
Provider Business Practice Location Address Fax Number:
509-532-8844
Provider Enumeration Date:
04/11/2022

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: 101YA0400X , with the licence number:  C061261876 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CO61261876 . This is a "INSURANCE BILLING" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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