1962601310 NPI number — KIM R CANTWELL-GAB ARNP

Table of content: KIM R CANTWELL-GAB ARNP (NPI 1962601310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962601310 NPI number — KIM R CANTWELL-GAB ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANTWELL-GAB
Provider First Name:
KIM
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1962601310
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 MEDICAL CENTER DR
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97504-4314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-732-7850
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1698 E MCANDREWS RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504-5589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-732-7850
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2007

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: 363L00000X , with the licence number:  AP30007760 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 201503207NP-PP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9653080 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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