Basic Information
| Provider Information | |||||||||
| NPI: | 1063137883 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN ARIZONA HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 S WILLARD ST | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863264126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286395580 | ||||||||
| FaxNumber: | 9286396541 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 S WILLARD ST | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863264126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286395580 | ||||||||
| FaxNumber: | 9286396541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2022 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | ACCOMANDO | ||||||||
| AuthorizedOfficialFirstName: | ELAINE | ||||||||
| AuthorizedOfficialMiddleName: | MARY | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 9286395580 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA-C | ||||||||
| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.