1922613058 NPI number — MICHELE ANNE GOBERN RADT

Table of content: MICHELE ANNE GOBERN RADT (NPI 1922613058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922613058 NPI number — MICHELE ANNE GOBERN RADT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOBERN
Provider First Name:
MICHELE
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RADT
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:
1922613058
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 GRAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95838-3512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-929-1951
Provider Business Mailing Address Fax Number:
916-929-5116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95838-3512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-929-1951
Provider Business Practice Location Address Fax Number:
916-929-5116
Provider Enumeration Date:
09/15/2020

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: R1379370320 . This is a "CCAPP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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