Basic Information
| Provider Information | |||||||||
| NPI: | 1235174731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PELLICORE | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | DEANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3620 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022307373 | ||||||||
| FaxNumber: | 6022305105 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 W WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | AVONDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853231848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022307373 | ||||||||
| FaxNumber: | 6022303086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01057388A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 48328 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200447730 | 05 | IN | MEDICAID | 857797 | 05 | AZ | MEDICAID | 000000305690 | 01 | BCBS PROVIDER NUMBER | OTHER |