1902454358 NPI number — MICHAEL TRAVIS SNIDER PHYSICIAN ASSISTANT

Table of content: MICHAEL TRAVIS SNIDER PHYSICIAN ASSISTANT (NPI 1902454358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902454358 NPI number — MICHAEL TRAVIS SNIDER PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SNIDER
Provider First Name:
MICHAEL
Provider Middle Name:
TRAVIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
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:
1902454358
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
830 US HIGHWAY 98 APT 832
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAPHNE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36526-5812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-582-1507
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 VETERANS AVE BLDG 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BILOXI
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39531-2410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-523-5599
Provider Business Practice Location Address Fax Number:
228-523-4526
Provider Enumeration Date:
08/29/2019

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 106405200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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