Provider Demographics
NPI:1528413150
Name:EFFIOM, JUAN-ITA (OTR)
Entity Type:Individual
Prefix:
First Name:JUAN-ITA
Middle Name:
Last Name:EFFIOM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7727 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-4320
Mailing Address - Country:US
Mailing Address - Phone:612-861-2135
Mailing Address - Fax:
Practice Address - Street 1:7727 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-4320
Practice Address - Country:US
Practice Address - Phone:612-861-2135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105137174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist