1922157445 NPI number — PATRICIA ANTTILA P.T.

Table of content: PATRICIA ANTTILA P.T. (NPI 1922157445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922157445 NPI number — PATRICIA ANTTILA P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANTTILA
Provider First Name:
PATRICIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KAPALA
Provider Other First Name:
PATRICIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922157445
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
270B COMMERCIAL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTOLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96122-9608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-832-9642
Provider Business Mailing Address Fax Number:
530-832-9643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
270 COMMERCIAL ST
Provider Second Line Business Practice Location Address:
B
Provider Business Practice Location Address City Name:
PORTOLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96122-9608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-832-9642
Provider Business Practice Location Address Fax Number:
530-832-9643
Provider Enumeration Date:
01/10/2007

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: 174400000X , with the licence number:  PT20786 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00046838 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0PT207860 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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