1881014702 NPI number — MARILYNN KIRCHUBEL P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881014702 NPI number — MARILYNN KIRCHUBEL P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIRCHUBEL
Provider First Name:
MARILYNN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
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:
1881014702
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2160 W GRANT LINE RD
Provider Second Line Business Mailing Address:
STE 230
Provider Business Mailing Address City Name:
TRACY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95377-7334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-832-8700
Provider Business Mailing Address Fax Number:
209-832-2210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2160 W GRANT LINE RD STE 230
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRACY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95377-7334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-832-8700
Provider Business Practice Location Address Fax Number:
209-832-2210
Provider Enumeration Date:
04/17/2014

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: 363AM0700X , with the licence number:  PA 11603 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PA 11603 . This is a "STATE OF CALIFORNIA PHYSICIAN ASSISTANT LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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