1962558569 NPI number — NORTHERN ARIZONA DERMATOLOGY CENTER PC

Table of content: (NPI 1962558569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962558569 NPI number — NORTHERN ARIZONA DERMATOLOGY CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN ARIZONA DERMATOLOGY CENTER PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1962558569
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1490 N TURQUOISE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-774-5074
Provider Business Mailing Address Fax Number:
928-779-0884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1490 N TURQUOISE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-774-5074
Provider Business Practice Location Address Fax Number:
928-779-0884
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KNUTSON
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
ACKERMAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
928-774-5074

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MICA010529 . This is a "LIABILITY INSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: MICA03976 . This is a "LIABILITY INSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 295114 . This is a "AHCCCS" identifier . This identifiers is of the category "OTHER".
  • Identifier: MICA03876 . This is a "LIABILITY INSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 19361 . This is a "AZ LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: MICA03874 . This is a "LIABILITY INSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 23222 . This is a "AZ LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 20368 . This is a "AZ LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: MICA03872 . This is a "LIABILITY INSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33121 . This is a "AZ LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 25924 . This is a "AZ LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 30215 . This is a "AZ LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: MICA014013 . This is a "LIABILITY INSURANCE" identifier . This identifiers is of the category "OTHER".




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