1295718278 NPI number — THERESA M WU P.A.-C.

Table of content: THERESA M WU P.A.-C. (NPI 1295718278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295718278 NPI number — THERESA M WU P.A.-C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WU
Provider First Name:
THERESA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HAVEMAN
Provider Other First Name:
THERESA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295718278
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6541 N MONTROSE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85741-3124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-769-0574
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
627 N SWAN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85711-2101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-308-8990
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/23/2005

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:  2453 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 86080015085259A665 . This is a "TRIWEST" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 970018753 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 556631 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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