1679629661 NPI number — VIOLA G MEDINA ARNP

Table of content: VIOLA G MEDINA ARNP (NPI 1679629661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679629661 NPI number — VIOLA G MEDINA ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA
Provider First Name:
VIOLA
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1679629661
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2940
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POULSBO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98370-2940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-979-0569
Provider Business Mailing Address Fax Number:
877-805-9505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19980 10TH AVE NE STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POULSBO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98370-6322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-979-0569
Provider Business Practice Location Address Fax Number:
877-805-9505
Provider Enumeration Date:
01/25/2007

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: 363L00000X , with the licence number:  AP30004058 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0039581 . This is a "LABOR AND INDUSTRIES #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9619594 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0359072 . This is a "LNI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: US2510511 . This is a "AETNA SPECIALIST PIN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7793ME . This is a "BLUE SHIELD #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 500017809 . This is a "RAILROAD MC#" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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