1871844894 NPI number — TERESA RENEE CHARVET PA-C

Table of content: TERESA RENEE CHARVET PA-C (NPI 1871844894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871844894 NPI number — TERESA RENEE CHARVET PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARVET
Provider First Name:
TERESA
Provider Middle Name:
RENEE
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:
1871844894
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
723 MEMORIAL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROSSER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99350-1524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-786-2222
Provider Business Mailing Address Fax Number:
509-786-6612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
336 CHARDONNAY AVE BLDG 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROSSER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-786-0031
Provider Business Practice Location Address Fax Number:
509-786-0047
Provider Enumeration Date:
10/01/2012

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: 363AM0700X , with the licence number:  OA60625869 , 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: 2022877 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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