1114002474 NPI number — SARAH L KJORSTAD MPT

Table of content: SARAH L KJORSTAD MPT (NPI 1114002474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114002474 NPI number — SARAH L KJORSTAD MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KJORSTAD
Provider First Name:
SARAH
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLIAMS
Provider Other First Name:
SARAH
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114002474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2170
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMNER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98390-0480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-840-2313
Provider Business Mailing Address Fax Number:
253-840-6340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25012 104TH AVE SE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
KENT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98030-2821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-856-3477
Provider Business Practice Location Address Fax Number:
253-856-3478
Provider Enumeration Date:
10/26/2006

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: 225100000X , with the licence number:  PT00008598 , 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: 8385361 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8930868 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 5720WI . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 182544 . This is a "DEPT OF LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: A018 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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