Basic Information
Provider Information | |||||||||
NPI: | 1316040298 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ABACAN | ||||||||
FirstName: | GLORIA | ||||||||
MiddleName: | CRESENCIA B. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ABACAN | ||||||||
OtherFirstName: | GLORIA | ||||||||
OtherMiddleName: | C. BALDEMOR | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 820 MEMORIAL ST | ||||||||
Address2: |   | ||||||||
City: | PROSSER | ||||||||
State: | WA | ||||||||
PostalCode: | 993502504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5097862010 | ||||||||
FaxNumber: | 5097881794 | ||||||||
Practice Location | |||||||||
Address1: | 820 MEMORIAL ST STE 1 | ||||||||
Address2: |   | ||||||||
City: | PROSSER | ||||||||
State: | WA | ||||||||
PostalCode: | 993502504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5097862010 | ||||||||
FaxNumber: | 5097881794 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2006 | ||||||||
LastUpdateDate: | 03/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00039221 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1306897681 | 01 |   | NPI PROSSER MEMORIAL | OTHER | 2035AB | 01 | WA | REGENCE | OTHER | 911019392 | 01 |   | COMMERCIAL | OTHER | 8265142 | 05 | WA |   | MEDICAID | 156636 | 01 | WA | L & I | OTHER | 22855 | 01 |   | GROUP HEALTH | OTHER | 8265142 | 01 | WA | CHPW | OTHER |