1184748212 NPI number — DR. JENNIFER LYNN BAYNOSA MD

Table of content: DR. JENNIFER LYNN BAYNOSA MD (NPI 1184748212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184748212 NPI number — DR. JENNIFER LYNN BAYNOSA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAYNOSA
Provider First Name:
JENNIFER
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DELA PENA
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184748212
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 516558
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90051-0596
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-671-2391
Provider Business Mailing Address Fax Number:
702-895-4014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1707 W CHARLESTON BLVD
Provider Second Line Business Practice Location Address:
#160
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89102-2351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-671-5150
Provider Business Practice Location Address Fax Number:
702-384-6493
Provider Enumeration Date:
03/16/2007

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: 208600000X , with the licence number:  12653 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086X0206X , with the licence number: 12653 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1184748212 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: V51698 . This is a "PTAN" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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