Basic Information
Provider Information | |||||||||
NPI: | 1235314089 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GARIBALDI | ||||||||
FirstName: | ANN | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1739 E BEVERLY AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | KINGMAN | ||||||||
State: | AZ | ||||||||
PostalCode: | 864093593 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282634722 | ||||||||
FaxNumber: | 9282634794 | ||||||||
Practice Location | |||||||||
Address1: | 2226 HUALAPAI MOUNTAIN RD STE 101 | ||||||||
Address2: |   | ||||||||
City: | KINGMAN | ||||||||
State: | AZ | ||||||||
PostalCode: | 864018374 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9286818530 | ||||||||
FaxNumber: | 9286818714 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2007 | ||||||||
LastUpdateDate: | 11/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1953 | AK | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 4249 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.