1477515864 NPI number — MR. CHANGIL LEE BACHMAN FNP

Table of content: MR. CHANGIL LEE BACHMAN FNP (NPI 1477515864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477515864 NPI number — MR. CHANGIL LEE BACHMAN FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACHMAN
Provider First Name:
CHANGIL
Provider Middle Name:
LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
M

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:
1477515864
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 ELDORADO PKWY, BOX 150-153
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRISCO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-598-1200
Provider Business Mailing Address Fax Number:
972-637-9272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1295 ARRINGTON RD STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEGE STATION
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77845-8603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-213-5218
Provider Business Practice Location Address Fax Number:
979-213-5219
Provider Enumeration Date:
04/03/2006

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: 363LF0000X , with the licence number:  AP113612 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 171954401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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