1417399585 NPI number — STACEY BOGDANOWICZ PHYSICIAN ASSISTANT

Table of content: STACEY BOGDANOWICZ PHYSICIAN ASSISTANT (NPI 1417399585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417399585 NPI number — STACEY BOGDANOWICZ PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOGDANOWICZ
Provider First Name:
STACEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
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:
1417399585
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2185
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99210-2185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-474-6842
Provider Business Mailing Address Fax Number:
509-474-6606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 S COWLEY ST STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-473-6706
Provider Business Practice Location Address Fax Number:
509-473-6704
Provider Enumeration Date:
07/18/2013

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:  PA23097 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA60449258 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2034728 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500669258 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".