1720150709 NPI number — LISA MCDANIEL PAC

Table of content: LISA MCDANIEL PAC (NPI 1720150709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720150709 NPI number — LISA MCDANIEL PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDANIEL
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLOUSE
Provider Other First Name:
LISA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720150709
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 756
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85299-0756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-355-8525
Provider Business Mailing Address Fax Number:
480-355-3115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3499 S MERCY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85297-0437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-355-8525
Provider Business Practice Location Address Fax Number:
480-355-3115
Provider Enumeration Date:
11/14/2006

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:  3546 , 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: 3546 . This is a "STATE LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 031813 . This is a "MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 031814 . This is a "MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 031820 . This is a "MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 183792 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 031815 . This is a "MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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