1487174348 NPI number — AMANDA LYN BISHOP OTR

Table of content: AMANDA LYN BISHOP OTR (NPI 1487174348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487174348 NPI number — AMANDA LYN BISHOP OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BISHOP
Provider First Name:
AMANDA
Provider Middle Name:
LYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BISHOP
Provider Other First Name:
AMANDA
Provider Other Middle Name:
LYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487174348
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
817 N 56TH AVE W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55807-1328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 LONDON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55804-2220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-428-5050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2017

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: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NA . This is a "NA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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