1629122825 NPI number — SANDRA M AUGUSTINE MA

Table of content: SANDRA M AUGUSTINE MA (NPI 1629122825)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629122825 NPI number — SANDRA M AUGUSTINE MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AUGUSTINE
Provider First Name:
SANDRA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA
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:
1629122825
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5455 ALMIRA DR SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREMERTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98311-8330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-373-5031
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5455 ALMIRA DR SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREMERTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98311-8330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-373-5031
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2007

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: 106H00000X , with the licence number:  LH00005152 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 228303 . This is a "MANAGED HEALTH NETWORK" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 91102010657 . This is a "KITSAP PHYSICIANS SERVICE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: A039 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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