1306163258 NPI number — MARVIN CABILANGAN DEPAS FNP

Table of content: MARVIN CABILANGAN DEPAS FNP (NPI 1306163258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306163258 NPI number — MARVIN CABILANGAN DEPAS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEPAS
Provider First Name:
MARVIN
Provider Middle Name:
CABILANGAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1306163258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3630
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86003-3630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-233-5110
Provider Business Mailing Address Fax Number:
928-774-6687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 N. 13TH WEST
Provider Second Line Business Practice Location Address:
NORTH COUNTRY HEALTHCARE, ST JOHNS
Provider Business Practice Location Address City Name:
SAINT JOHNS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-337-3705
Provider Business Practice Location Address Fax Number:
928-337-3780
Provider Enumeration Date:
04/30/2010

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: 363LF0000X , with the licence number:  AP3566 , 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: 516484 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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