1629724075 NPI number — JOSE RAMON SANCHEZ BASTIDAS NP-C

Table of content: JOSE RAMON SANCHEZ BASTIDAS NP-C (NPI 1629724075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629724075 NPI number — JOSE RAMON SANCHEZ BASTIDAS NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANCHEZ BASTIDAS
Provider First Name:
JOSE
Provider Middle Name:
RAMON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
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:
1629724075
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 617
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERTON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85350-0617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-315-7910
Provider Business Mailing Address Fax Number:
928-722-6113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1453 N MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
SAN LUIS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-459-3508
Provider Business Practice Location Address Fax Number:
928-459-3515
Provider Enumeration Date:
02/24/2022

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:  271774 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: RN180685 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 121183 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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