1982961611 NPI number — KRISTIN ANGELINE CAMP SPERBER PA-C

Table of content: KRISTIN ANGELINE CAMP SPERBER PA-C (NPI 1982961611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982961611 NPI number — KRISTIN ANGELINE CAMP SPERBER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPERBER
Provider First Name:
KRISTIN
Provider Middle Name:
ANGELINE CAMP
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1982961611
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 STRATTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUTLAND
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05701-4621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-855-2027
Provider Business Mailing Address Fax Number:
802-855-2053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 STRATTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUTLAND
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05701-4621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-773-3386
Provider Business Practice Location Address Fax Number:
802-773-4578
Provider Enumeration Date:
04/19/2012

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:  055.0031129 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9000560 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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