1104828276 NPI number — MS. JAYNE ELLEN PEAK APN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104828276 NPI number — MS. JAYNE ELLEN PEAK APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEAK
Provider First Name:
JAYNE
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILMORE
Provider Other First Name:
JAYNE
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104828276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17015 N. 130TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUN CITY WEST
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85375
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-269-3162
Provider Business Mailing Address Fax Number:
563-421-3129

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9900 BREN ROAD EAST
Provider Second Line Business Practice Location Address:
MAIL ROUTE MN 008-B213
Provider Business Practice Location Address City Name:
MINNETONKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-561-0861
Provider Business Practice Location Address Fax Number:
563-421-3129
Provider Enumeration Date:
06/02/2005

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: 363LF0000X , with the licence number:  AP7967 , 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: 15939 . This is a "IOWA MIDLANDS CHOICE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 03262 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1583450 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2583450 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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