Basic Information
| Provider Information | |||||||||
| NPI: | 1225228901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARDY | ||||||||
| FirstName: | JOLENE | ||||||||
| MiddleName: | CLARK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | JOLENE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 13627 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857323627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207507160 | ||||||||
| FaxNumber: | 5208861929 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 E RIVER RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203219850 | ||||||||
| FaxNumber: | 5203219005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2007 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 80870 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 7621240-1205 | UT | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 40282 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 40282 | 01 | AZ | STATE LICENSE | OTHER |