Basic Information
| Provider Information | |||||||||
| NPI: | 1477539138 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIACOLETTO | ||||||||
| FirstName: | LAURIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 S CLEARVIEW AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852093378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809889108 | ||||||||
| FaxNumber: | 4808134460 | ||||||||
| Practice Location | |||||||||
| Address1: | 407 N LINDSAY RD STE 103-104 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852137710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808070084 | ||||||||
| FaxNumber: | 4808070091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 04/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9289 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 5413 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | Z162194 | 01 | MEDICARE PTAN | OTHER | 859739 | 05 | AZ | MEDICAID |