1124275847 NPI number — MS. DEBRA LYNN GROMACKI-BLYTH PA-C

Table of content: MS. DEBRA LYNN GROMACKI-BLYTH PA-C (NPI 1124275847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124275847 NPI number — MS. DEBRA LYNN GROMACKI-BLYTH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROMACKI-BLYTH
Provider First Name:
DEBRA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
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:
1124275847
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31720 TEMECULA PKWY
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
TEMECULA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92592-5802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-303-6900
Provider Business Mailing Address Fax Number:
951-303-2900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31720 TEMECULA PKWY
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
TEMECULA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92592-5802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-303-6900
Provider Business Practice Location Address Fax Number:
951-303-2900
Provider Enumeration Date:
08/25/2008

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:  PA10615 , 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)





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