Basic Information
| Provider Information | |||||||||
| NPI: | 1063855088 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OSNA PRIMARY CARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEZONA ORTHOPAEDIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 271429 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841271429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027723800 | ||||||||
| FaxNumber: | 6027723801 | ||||||||
| Practice Location | |||||||||
| Address1: | 2940 E BANNER GATEWAY DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809642908 | ||||||||
| FaxNumber: | 4808332136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2013 | ||||||||
| LastUpdateDate: | 02/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | KINNA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6027723800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OSNA PRIMARY CARE, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.