1962047720 NPI number — AUBREY JAYNE MINOR COTA

Table of content: AUBREY JAYNE MINOR COTA (NPI 1962047720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962047720 NPI number — AUBREY JAYNE MINOR COTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MINOR
Provider First Name:
AUBREY
Provider Middle Name:
JAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
COTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KAGARISE
Provider Other First Name:
AUBREY
Provider Other Middle Name:
JAYNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
COTA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962047720
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
353 FAIRMONT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAPID CITY
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57701-7375
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-755-1140
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
353 FAIRMONT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAPID CITY
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57701-7375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-755-1100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2019

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: 224Z00000X , with the licence number:  388A , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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