Basic Information
| Provider Information | |||||||||
| NPI: | 1306163258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEPAS | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | CABILANGAN | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3630 | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860033630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282335110 | ||||||||
| FaxNumber: | 9287746687 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 N. 13TH WEST | ||||||||
| Address2: | NORTH COUNTRY HEALTHCARE, ST JOHNS | ||||||||
| City: | SAINT JOHNS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283373705 | ||||||||
| FaxNumber: | 9283373780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2010 | ||||||||
| LastUpdateDate: | 10/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP3566 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 516484 | 05 | AZ | MEDICAID |