1417159807 NPI number — WILKINSON SNOWDEN OTOLARYNGOLOGY CONSULTANTS, P.A.

Table of content: KRISTEN ELAINE FRALEY PT, DPT (NPI 1972045730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417159807 NPI number — WILKINSON SNOWDEN OTOLARYNGOLOGY CONSULTANTS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILKINSON SNOWDEN OTOLARYNGOLOGY CONSULTANTS, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1417159807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14546 SAINT AUGUSTINE RD
Provider Second Line Business Mailing Address:
STE 401
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32258-5468
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-268-5366
Provider Business Mailing Address Fax Number:
904-268-5457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14546 SAINT AUGUSTINE RD
Provider Second Line Business Practice Location Address:
STE 401
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32258-5468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-268-5366
Provider Business Practice Location Address Fax Number:
904-268-5457
Provider Enumeration Date:
06/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILKINSON
Authorized Official First Name:
ALBERT
Authorized Official Middle Name:
H
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
904-268-5366

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME81538 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: ME56965 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 45761 . This is a "BCBS GROUP PROVIDER #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: CJ2313 . This is a "RAILROAD GROUP #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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