1427159409 NPI number — MRS. SUZANNE KAY MCKENNA-STUKAS MS OTR

Table of content: MRS. SUZANNE KAY MCKENNA-STUKAS MS OTR (NPI 1427159409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427159409 NPI number — MRS. SUZANNE KAY MCKENNA-STUKAS MS OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKENNA-STUKAS
Provider First Name:
SUZANNE
Provider Middle Name:
KAY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STUKAS
Provider Other First Name:
SUZANNE
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1427159409
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2233 MUIR WDS PLACE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVIS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-756-3183
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2019 ANDERSON RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
DAVIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-758-2222
Provider Business Practice Location Address Fax Number:
530-758-2283
Provider Enumeration Date:
09/25/2006

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: 225X00000X , with the licence number:  OT3152 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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