1750853909 NPI number — MR. RONALD EUGENE LAST JR. CDP-T

Table of content: MR. RONALD EUGENE LAST JR. CDP-T (NPI 1750853909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750853909 NPI number — MR. RONALD EUGENE LAST JR. CDP-T

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAST
Provider First Name:
RONALD
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
CDP-T
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:
1750853909
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1321 ECKARD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ANGELES
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98362-2785
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-477-3749
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 N RACE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ANGELES
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98362-3513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-452-2442
Provider Business Practice Location Address Fax Number:
360-452-2738
Provider Enumeration Date:
12/28/2018

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: 101YA0400X , with the licence number:  60870731 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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