1356814974 NPI number — FERRIS ANTWAN ALSTON

Table of content: FERRIS ANTWAN ALSTON (NPI 1356814974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356814974 NPI number — FERRIS ANTWAN ALSTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALSTON
Provider First Name:
FERRIS
Provider Middle Name:
ANTWAN
Provider Name Prefix Text:
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:
1356814974
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 VERMONT AVE NW STE 1003
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20005-4927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-381-4432
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 MLK JR AVE S.E.
Provider Second Line Business Practice Location Address:
SUITE#100
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-849-1016
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/07/2019

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: 3747P1801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4422334 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".




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