1861584401 NPI number — GORDAYNE E GRIFFIN FNP

Table of content: GORDAYNE E GRIFFIN FNP (NPI 1861584401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861584401 NPI number — GORDAYNE E GRIFFIN FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIFFIN
Provider First Name:
GORDAYNE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EGBERT
Provider Other First Name:
GORDAYNE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1861584401
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10414
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LARGO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33773-0414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-632-6074
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
706 PINEYWOOD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THOMASVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27360-2753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-632-6074
Provider Business Practice Location Address Fax Number:
866-341-7509
Provider Enumeration Date:
09/29/2006

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: 163WP0809X , with the licence number:  RN034545 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 200735 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00229542 . This is a "RR MEDICARE # - PARADIGM" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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