1770944779 NPI number — MARI KRISEL LANTIN SALAZAR PA-C

Table of content: MARI KRISEL LANTIN SALAZAR PA-C (NPI 1770944779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770944779 NPI number — MARI KRISEL LANTIN SALAZAR PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SALAZAR
Provider First Name:
MARI KRISEL
Provider Middle Name:
LANTIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1770944779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2722 MERRILEE DR
Provider Second Line Business Mailing Address:
STE 230
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22031-4400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-698-4444
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
199 REEDSDALE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02186-3926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-696-4600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/18/2016

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: 363AS0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 0110007749 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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