1962548263 NPI number — MISS AFRA M ROET P.A.

Table of content: MISS AFRA M ROET P.A. (NPI 1962548263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962548263 NPI number — MISS AFRA M ROET P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROET
Provider First Name:
AFRA
Provider Middle Name:
M
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
P.A.
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:
1962548263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1250 CLEVELAND AVE
Provider Second Line Business Mailing Address:
305
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92103-7300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-300-1320
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2743 HIGHLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NATIONAL CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91950-7410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-474-2284
Provider Business Practice Location Address Fax Number:
619-474-3919
Provider Enumeration Date:
01/30/2007

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: 363A00000X , with the licence number:  PA11803 , 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: PA11803 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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