Basic Information
| Provider Information | |||||||||
| NPI: | 1013305283 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORTENSEN | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 E ROUTE 66 STE 100 | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860014772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287739695 | ||||||||
| FaxNumber: | 9287730208 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 S THOMPSON ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860018759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282266400 | ||||||||
| FaxNumber: | 9282266410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2014 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.