Basic Information
| Provider Information | |||||||||
| NPI: | 1407302300 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SILVEIRA | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WADE/HAUGEN | ||||||||
| OtherFirstName: | GINA | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3630 | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860033630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285374300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2650 E SHOW LOW LAKE RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285374300 | ||||||||
| FaxNumber: | 9285374320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2016 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 95004773 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.