1881641686 NPI number — VERNON NESSAN MD

Table of content: VERNON NESSAN MD (NPI 1881641686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881641686 NPI number — VERNON NESSAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NESSAN
Provider First Name:
VERNON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1881641686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98371-0137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-697-5502
Provider Business Mailing Address Fax Number:
253-697-5510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 23RD AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98372-4661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-841-4378
Provider Business Practice Location Address Fax Number:
253-841-5881
Provider Enumeration Date:
05/27/2006

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: 207RP1001X , with the licence number:  MD00013833 , 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: 1665702 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0155123 . This is a "L & I PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 91120349463 . This is a "KPS PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 98372K003 . This is a "TRICARE PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: NE2298 . This is a "REGENCE RIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 4330437 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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