1790244341 NPI number — AMERICAN ADVANCED PRACTICE NETWORK, P.C.

Table of content: (NPI 1790244341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790244341 NPI number — AMERICAN ADVANCED PRACTICE NETWORK, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMERICAN ADVANCED PRACTICE NETWORK, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1790244341
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 269083
Provider Second Line Business Mailing Address:
LOCKBOX #2035
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73126-9083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1056 29TH ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57201-9120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-753-0960
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/13/2019

Additional Information

Authorized Official

Authorized Official Last Name:
EWALT
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OPERATIONS DIRECTOR
Authorized Official Telephone Number:
646-970-3538

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 114038200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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