1689645467 NPI number — ABBY MICHELE NASTERNAK PA C

Table of content: ABBY MICHELE NASTERNAK PA C (NPI 1689645467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689645467 NPI number — ABBY MICHELE NASTERNAK PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NASTERNAK
Provider First Name:
ABBY
Provider Middle Name:
MICHELE
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:
JOHNSON
Provider Other First Name:
ABBY
Provider Other Middle Name:
MICHELE
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:
1689645467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 N THUNDERBIRD CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85215-1214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-353-2235
Provider Business Mailing Address Fax Number:
480-776-0025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9494 W NORTHERN AVE
Provider Second Line Business Practice Location Address:
101
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85305-1118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-872-2226
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2006

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:  3033 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 885048 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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