1285713271 NPI number — ROGER C GRAYSON PAC MPAB

Table of content: ROGER C GRAYSON PAC MPAB (NPI 1285713271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285713271 NPI number — ROGER C GRAYSON PAC MPAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAYSON
Provider First Name:
ROGER
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC MPAB
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285713271
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
419 SOUTH L STREET SUITE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-383-5949
Provider Business Mailing Address Fax Number:
253-383-5953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
419 SOUTH L STREET SUITE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-383-5949
Provider Business Practice Location Address Fax Number:
253-383-5953
Provider Enumeration Date:
11/02/2006

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR6977 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1784206 . This is a "PREMERA BLUE CROSS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: GAB25485 . This is a "MEDICARE PIERCE COUNTY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8357030 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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