1730412396 NPI number — MR. JASON WAYNE KONEMAN CPHT

Table of content: MR. JASON WAYNE KONEMAN CPHT (NPI 1730412396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730412396 NPI number — MR. JASON WAYNE KONEMAN CPHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONEMAN
Provider First Name:
JASON
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CPHT
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:
1730412396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 170700
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78717-0033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-981-5828
Provider Business Mailing Address Fax Number:
512-541-2868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10101 W PARMER LN APT 1314
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78717-5031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-981-5828
Provider Business Practice Location Address Fax Number:
512-541-2868
Provider Enumeration Date:
09/15/2009

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: 172V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183700000X , with the licence number: 102114 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183700000X , with the licence number: 260101030750018 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 305S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102114 . This is a "TEXAS STATE BOARD OF PHARMACY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".