Basic Information
Provider Information | |||||||||
NPI: | 1386021400 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FINCH | ||||||||
FirstName: | GLENN | ||||||||
MiddleName: | MICAH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSN, RN, FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1168 S AMITY LN | ||||||||
Address2: |   | ||||||||
City: | EAGAR | ||||||||
State: | AZ | ||||||||
PostalCode: | 859250017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282459857 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 488 S MOUNTAIN AVE | ||||||||
Address2: |   | ||||||||
City: | SPRINGERVILLE | ||||||||
State: | AZ | ||||||||
PostalCode: | 85938 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9283330127 | ||||||||
FaxNumber: | 9283334799 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/27/2015 | ||||||||
LastUpdateDate: | 03/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP7888 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 033179 | 05 | AZ |   | MEDICAID |