1689816563 NPI number — BRANDY PUGMIRE PN

Table of content: BRANDY PUGMIRE PN (NPI 1689816563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689816563 NPI number — BRANDY PUGMIRE PN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUGMIRE
Provider First Name:
BRANDY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PN
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:
1689816563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT HALL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83203-0306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-238-2400
Provider Business Mailing Address Fax Number:
208-238-5462

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
717 MISSION RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT HALL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83203-0717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-2400
Provider Business Practice Location Address Fax Number:
208-238-5462
Provider Enumeration Date:
03/24/2009

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: 164W00000X , with the licence number:  PN 14030 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003399100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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