1366532053 NPI number — MS. STACEY ANN BAUER PAC

Table of content: MS. STACEY ANN BAUER PAC (NPI 1366532053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366532053 NPI number — MS. STACEY ANN BAUER PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAUER
Provider First Name:
STACEY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

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:
1366532053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 PERIMETER PARK DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORRISVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27560-8442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
984-215-4110
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2605 BLUE RIDGE RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-787-3448
Provider Business Practice Location Address Fax Number:
919-232-0006
Provider Enumeration Date:
10/13/2006

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 , with the licence number:  103702 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 89013NA , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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