1629400361 NPI number — ANDRA SHARP DPT

Table of content: ANDRA SHARP DPT (NPI 1629400361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629400361 NPI number — ANDRA SHARP DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHARP
Provider First Name:
ANDRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOODS
Provider Other First Name:
ANDRA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629400361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13336 INDUSTRIAL RD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68137-1124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-330-3211
Provider Business Mailing Address Fax Number:
402-330-5970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13336 INDUSTRIAL RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68137-1124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-330-3211
Provider Business Practice Location Address Fax Number:
402-330-5970
Provider Enumeration Date:
08/05/2013

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:  3271 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

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




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