1770840266 NPI number — DR. AMELIA ROSE BUBEN DO

Table of content: DR. AMELIA ROSE BUBEN DO (NPI 1770840266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770840266 NPI number — DR. AMELIA ROSE BUBEN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUBEN
Provider First Name:
AMELIA
Provider Middle Name:
ROSE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1770840266
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25608
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84125-0608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-320-4476
Provider Business Mailing Address Fax Number:
206-568-7043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5350 TALLMAN AVE NW STE 420
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98107-5902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-781-6080
Provider Business Practice Location Address Fax Number:
206-781-6285
Provider Enumeration Date:
04/20/2012

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: 207V00000X , with the licence number:  OP60654007 , 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)

  • Identifier: 2065321 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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