1538264486 NPI number — MARILYN J NISHI-GORMELY PT

Table of content: MARILYN J NISHI-GORMELY PT (NPI 1538264486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538264486 NPI number — MARILYN J NISHI-GORMELY PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NISHI-GORMELY
Provider First Name:
MARILYN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1538264486
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14520 MONO WAY
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
SONORA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95370-9500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-533-1273
Provider Business Mailing Address Fax Number:
209-533-1382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14520 MONO WAY
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
SONORA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95370-9500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-533-1273
Provider Business Practice Location Address Fax Number:
209-533-1382
Provider Enumeration Date:
09/14/2006

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: 225100000X , with the licence number:  PT97780 , 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: P00064243 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ39907Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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