Basic Information
| Provider Information | |||||||||
| NPI: | 1023216249 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE LITTLE CLINIC OF ARIZONA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 932958 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154254200 | ||||||||
| FaxNumber: | 6158915244 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 S WATSON RD | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853266303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2324153226 | ||||||||
| FaxNumber: | 6232415323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | WATKINS | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 6154254200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | OTC 4233 | AZ | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | OTC 4233 | AZ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.