Basic Information
Provider Information | |||||||||
NPI: | 1205326824 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IRVIN | ||||||||
FirstName: | JUSTIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | EMT-P | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 118 E HASKELL ST | ||||||||
Address2: |   | ||||||||
City: | WINNEMUCCA | ||||||||
State: | NV | ||||||||
PostalCode: | 894453299 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7756235222 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 118 E HASKELL ST | ||||||||
Address2: |   | ||||||||
City: | WINNEMUCCA | ||||||||
State: | NV | ||||||||
PostalCode: | 894453247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7756235222 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2018 | ||||||||
LastUpdateDate: | 05/18/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146L00000X | 74571 | NV | Y |   | Emergency Medical Service Providers | Emergency Medical Technician, Paramedic |   |
No ID Information.