1831763622 NPI number — JORDAN LYNN BLAUFUSS NP-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831763622 NPI number — JORDAN LYNN BLAUFUSS NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAUFUSS
Provider First Name:
JORDAN
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-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:
1831763622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 W 15TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EMPORIA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66801-5367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-342-4864
Provider Business Mailing Address Fax Number:
620-343-3545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 W 15TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMPORIA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66801-5367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-424-8646
Provider Business Practice Location Address Fax Number:
620-343-3545
Provider Enumeration Date:
05/17/2021

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: 207Q00000X , with the licence number:  53-80200-072 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 80200 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201334100A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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