1699819060 NPI number — GERILYN JEAN AMAN OTRL

Table of content: GERILYN JEAN AMAN OTRL (NPI 1699819060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699819060 NPI number — GERILYN JEAN AMAN OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AMAN
Provider First Name:
GERILYN
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOFFER
Provider Other First Name:
GERILYN
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTRL
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699819060
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:
25989 SW NICOLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORVALLIS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97333-9340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-757-2754
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 N 20TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILOMATH
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97370-9621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-368-4313
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/17/2007

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: 225XP0200X , with the licence number:  340307 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 235118 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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