1174587323 NPI number — CHRISTINE MASAKO PRATT PA-C

Table of content: CHRISTINE MASAKO PRATT PA-C (NPI 1174587323)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174587323 NPI number — CHRISTINE MASAKO PRATT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRATT
Provider First Name:
CHRISTINE
Provider Middle Name:
MASAKO
Provider Name Prefix Text:
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:
KIMURA
Provider Other First Name:
CHRISTINE
Provider Other Middle Name:
MASAKO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C, MPAS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174587323
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3982 MULLIKIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMER
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99603-7400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-271-0342
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
880 EAST END ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMER
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99603-7400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-226-2228
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2006

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: 363AM0700X , with the licence number:  AMD-264 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 5194715-1206 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PAD1110 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 576150 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000256453 . This is a "HMSA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".