1629549415 NPI number — JOLLIEN TUSHABE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629549415 NPI number — JOLLIEN TUSHABE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUSHABE
Provider First Name:
JOLLIEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1629549415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7010 MN-7,
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. LOUIS PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55426-1809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-814-0207
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7010 HIGHWAY 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST LOUIS PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55426-4223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-889-0278
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2018

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 181205001452 . This is a "NON" identifier . This identifiers is of the category "OTHER".




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