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NPI
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1477175446
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10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider.
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Entity Type
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Individual
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Code describing the type of health care provider that is being assigned an NPI. Codes are:
- 1 = (Person): individual human being who furnishes health care;
- 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
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Is Sole Proprietor
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Y
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Indicate whether provider is a sole proprietor.
- A sole proprietor is the sole (the only) owner of a business that is not incorporated; that unincorporated business is a sole proprietorship.
- In a sole proprietorship, the sole proprietor owns all of the assets of the business and is solely liable for all of the debts of the business.
- There is no difference between a sole proprietorship and a sole proprietor; they are legally a single entity: an individual.
- In terms of NPI assignment, a sole proprietor is an Entity type 1 (Individual) and is eligible for only one NPI (the sole proprietorship business is not eligible for its own NPI).
- As an individual, a sole proprietorship cannot be a subpart and cannot have subparts. (See NPI Final Rule for information about subparts.)
- A sole proprietorship may or may not have employees.
- Often, the IRS assigns an EIN to a sole proprietorship in order to protect the sole proprietor's SSN from disclosure in claims or on W-2s. NPPES does not capture a sole proprietorship's EIN.
- Many types of health care providers could be sole proprietorships (for example, group practices, pharmacies, home health agencies).
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Provider Last Name (Legal Name)
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HARZAN
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The last name of the provider (if an individual). If the provider is an individual, this is the legal name. This name must match the name on file with the Social Security Administration (SSA). In addition, the date of birth must match that on file with SSA. (First and last names are required for initial applications.) The First, Middle, Last and Credential(s) fields allow the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters.
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Provider First Name
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MIMI
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The first name of the provider, if the provider is an individual.
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Provider Credential Text
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MSPA, PA-C
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The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.
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Provider Other Last Name
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CHARTER
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Other last name by which the provider being identified is or has been known (if an individual)
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Provider Other First Name
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MIMI
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Other first name by which the provider being identified is or has been known (if an individual). This may be the same as the ''Provider first name'' if the provider is or has been known by a different last name only.
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Provider Other Credential Text
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MSPA, PA-C
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Provider Other Credential Text
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Provider Other Last Name Type Code
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1
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Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 5 = other.
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Provider First Line Business Mailing Address
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PO BOX 3988
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The first line mailing address of the provider being identified. This data element may contain the same information as ''Provider first line location address''.
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Provider Business Mailing Address City Name
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CARBONDALE
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The City name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address City name''.
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Provider Business Mailing Address State Name
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IL
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The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address State name''.
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Provider Business Mailing Address Postal Code
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62902-3988
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The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ''Provider location address postal code''.
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Provider Business Mailing Address Country Code
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US
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The country code in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address country code''.
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Provider Business Mailing Address Telephone Number
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618-457-5200
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The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ''Provider location address telephone number''.
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Provider First Line Business Practice Location Address
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2200 NE NEFF RD STE 302
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The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
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Provider Business Practice Location Address City Name
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BEND
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The city name in the location address of the provider being identified.
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Provider Business Practice Location Address State Name
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OR
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The State or Province name in the location address of the provider being identified.
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Provider Business Practice Location Address Postal Code
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97701-4279
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The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
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Provider Business Practice Location Address Country Code
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US
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The country code in the location address of the provider being identified.
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Provider Business Practice Location Address Telephone Number
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541-706-6915
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The telephone number associated with the location address of the provider being identified.
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Provider Business Practice Location Address Fax Number
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541-706-6733
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The fax number associated with the location address of the provider being identified.
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Provider Enumeration Date
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05/13/2020
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The date the provider was assigned a unique identifier (assigned an NPI).
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Last Update Date
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10/01/2025
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The date that a record was last updated or changed.
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Provider Gender Code
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F
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The code designating the provider's gender if the provider is a person.
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Provider Gender
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Female
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The provider's gender if the provider is a person.
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Healthcare Provider Taxonomy Code #1
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363AM0700X
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The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization.
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Healthcare Provider Taxonomy 1
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Medical Physician Assistant
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Healthcare Provider Taxonomy #1
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Healthcare Provider Primary Taxonomy Switch 1
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N
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Primary Taxonomy:
- X - The primary taxonomy switch is Not Answered;
- Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);
- N - The taxonomy is not the primary taxonomy.
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Healthcare Provider Taxonomy Code 2
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390200000X
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Healthcare Provider Taxonomy Code #2
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Healthcare Provider Taxonomy 2
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Student in an Organized Health Care Education/Training Program
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Healthcare Provider Taxonomy #2
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Healthcare Provider Primary Taxonomy Switch 2
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N
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Primary Taxonomy:
- X - The primary taxonomy switch is Not Answered;
- Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);
- N - The taxonomy is not the primary taxonomy.
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Healthcare Provider Taxonomy Code 3
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363A00000X
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Healthcare Provider Taxonomy Code #3
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Healthcare Provider Taxonomy 3
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Physician Assistant
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Healthcare Provider Taxonomy #3
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Provider License Number 3
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085008538
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Provider License Number #3
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Provider License Number State Code 3
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IL
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Provider License Number State Code #3
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Healthcare Provider Primary Taxonomy Switch 3
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Y
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Primary Taxonomy:
- X - The primary taxonomy switch is Not Answered;
- Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);
- N - The taxonomy is not the primary taxonomy.
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Certification Date
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10/01/2025
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Certification Date
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