1780989590 NPI number — HOANG KIM PETERSEN NURSE PRACTITIONER

Table of content: HOANG KIM PETERSEN NURSE PRACTITIONER (NPI 1780989590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780989590 NPI number — HOANG KIM PETERSEN NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
HOANG
Provider Middle Name:
KIM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
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:
1780989590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 N THUNDERBIRD CIR STE 303
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85215-1219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-455-4932
Provider Business Mailing Address Fax Number:
480-776-0025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16728 E SMOKY HILL RD UNIT 10D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTENNIAL
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80015-2400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-766-7006
Provider Business Practice Location Address Fax Number:
303-766-1023
Provider Enumeration Date:
01/26/2011

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: 363LP0200X , with the licence number:  1649 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: NP-10342 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 283185101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 283185102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 78459834 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 283185104 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200342180 A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 283185103 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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