1063991974 NPI number — MRS. SAWYER RAE SHAMBURGER OTA

Table of content: MRS. SAWYER RAE SHAMBURGER OTA (NPI 1063991974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063991974 NPI number — MRS. SAWYER RAE SHAMBURGER OTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAMBURGER
Provider First Name:
SAWYER
Provider Middle Name:
RAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTA
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:
1063991974
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3232 OLD HIGHWAY 70
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARDMORE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-388-6563
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 NORTH PRAIRE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PILOT POINT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
73401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-324-6620
Provider Business Practice Location Address Fax Number:
940-324-6624
Provider Enumeration Date:
08/10/2018

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: 224Z00000X , with the licence number:  211887 , 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)





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