1245838689 NPI number — DR. JETT NYMANN DELACRUZ PARAOAN PHARMD, MBA

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 1245838689 NPI number — DR. JETT NYMANN DELACRUZ PARAOAN PHARMD, MBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARAOAN
Provider First Name:
JETT NYMANN
Provider Middle Name:
DELACRUZ
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD, MBA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PARAOAN
Provider Other First Name:
JETT
Provider Other Middle Name:
DELACRUZ
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHARMD, MBA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1245838689
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
905 N TUCKER AVE APT 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87401-7566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-441-2599
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
US-491
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHIPROCK
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87420-8742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-368-7250
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2020

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: 183500000X , with the licence number:  0202214586 , 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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