1922073527 NPI number — STACEY R. KOFMAN ATC, PTA

Table of content: STACEY R. KOFMAN ATC, PTA (NPI 1922073527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922073527 NPI number — STACEY R. KOFMAN ATC, PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOFMAN
Provider First Name:
STACEY
Provider Middle Name:
R.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC, PTA
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:
1922073527
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:
49 SHOWERS DR
Provider Second Line Business Mailing Address:
J324
Provider Business Mailing Address City Name:
MOUNTAIN VIEW
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94040-1463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-949-4561
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 EMBARCADERO RD
Provider Second Line Business Practice Location Address:
PALO ALTO HIGH SCHOOL
Provider Business Practice Location Address City Name:
PALO ALTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94301-2321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-329-3892
Provider Business Practice Location Address Fax Number:
650-566-0612
Provider Enumeration Date:
02/17/2006

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: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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