1295236792 NPI number — MR. EDWAR JOSE FERNANDO ESTUPINIAN

Table of content: MR. EDWAR JOSE FERNANDO ESTUPINIAN (NPI 1295236792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295236792 NPI number — MR. EDWAR JOSE FERNANDO ESTUPINIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ESTUPINIAN
Provider First Name:
EDWAR
Provider Middle Name:
JOSE FERNANDO
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1295236792
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2225 PACIFIC BLVD SE STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97321-7903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-286-5002
Provider Business Mailing Address Fax Number:
541-246-8826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2225 PACIFIC BLVD SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97321-7907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-286-5002
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2018

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: C6204 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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