1104933241 NPI number — MRS. DEVON ADAIR BATHURST PA-C

Table of content: MRS. DEVON ADAIR BATHURST PA-C (NPI 1104933241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104933241 NPI number — MRS. DEVON ADAIR BATHURST PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BATHURST
Provider First Name:
DEVON
Provider Middle Name:
ADAIR
Provider Name Prefix Text:
MRS.
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:
COELLNER
Provider Other First Name:
DEVON
Provider Other Middle Name:
ADAIR
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104933241
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 OAKFIELD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33511-5779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-681-5551
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BRANDON REGIONAL HOSPITAL
Provider Second Line Business Practice Location Address:
119 OAKFIELD DR.
Provider Business Practice Location Address City Name:
BRANDON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-681-5551
Provider Business Practice Location Address Fax Number:
757-686-0541
Provider Enumeration Date:
08/24/2006

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:  0110001432 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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