1477094522 NPI number — MRS. TIA CHEYENNE SUTTON MSOTR/L

Table of content: MRS. TIA CHEYENNE SUTTON MSOTR/L (NPI 1477094522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477094522 NPI number — MRS. TIA CHEYENNE SUTTON MSOTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUTTON
Provider First Name:
TIA
Provider Middle Name:
CHEYENNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSOTR/L
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:
1477094522
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 S YELLOWSTONE AVE
Provider Second Line Business Mailing Address:
APT. 2
Provider Business Mailing Address City Name:
BOZEMAN
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59718-1913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-698-8467
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 E MAIN ST
Provider Second Line Business Practice Location Address:
C
Provider Business Practice Location Address City Name:
BOZEMAN
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59715-3719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-522-3722
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2017

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:  OTP-OT-LIC-4729 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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