1679692511 NPI number — WALLY STURGIS PA

Table of content: WALLY STURGIS PA (NPI 1679692511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679692511 NPI number — WALLY STURGIS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STURGIS
Provider First Name:
WALLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1679692511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14 HIGH VALLEY ESTATES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDER
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28701-9726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-683-4437
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 TABERNACLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACK MOUNTAIN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28711-2526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-669-3496
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2007

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: 363AM0700X , with the licence number:  100651 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100651 . This is a "MEDICAL BOARD NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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