Basic Information
| Provider Information | |||||||||
| NPI: | 1487605481 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VAL VISTA LAKES FAMILY MEDICINE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3331 E BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805451100 | ||||||||
| FaxNumber: | 4805457181 | ||||||||
| Practice Location | |||||||||
| Address1: | 3331 E BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805451100 | ||||||||
| FaxNumber: | 4805457181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2006 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | HATFIELD | ||||||||
| AuthorizedOfficialFirstName: | KENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4805451100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.