1639175052 NPI number — STEPHANIE KAY CAPEHART PA-C

Table of content: STEPHANIE KAY CAPEHART PA-C (NPI 1639175052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639175052 NPI number — STEPHANIE KAY CAPEHART PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAPEHART
Provider First Name:
STEPHANIE
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TALBOTT
Provider Other First Name:
STEHANIE
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639175052
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3420 22ND PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79410-1314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-725-5844
Provider Business Mailing Address Fax Number:
806-723-6532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4102 24TH ST
Provider Second Line Business Practice Location Address:
STE. 403
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79410-1806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-725-7150
Provider Business Practice Location Address Fax Number:
806-723-6136
Provider Enumeration Date:
06/21/2005

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: 363A00000X , with the licence number:  PA04001 , 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: 321200301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8271NA . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 138110102 . This is a "FIRSTCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 56059531 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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