1740892868 NPI number — ADAM DANE BERNARD FNP-C

Table of content: ADAM DANE BERNARD FNP-C (NPI 1740892868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740892868 NPI number — ADAM DANE BERNARD FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERNARD
Provider First Name:
ADAM
Provider Middle Name:
DANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
M

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:
1740892868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
556 FAWN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIFFIN
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52340-4722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-799-0894
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2162 W KIMBERLY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52806-5368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-391-1024
Provider Business Practice Location Address Fax Number:
563-386-0965
Provider Enumeration Date:
08/19/2020

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: 363L00000X , with the licence number:  A156111 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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