Basic Information
| Provider Information | |||||||||
| NPI: | 1588741615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TVETEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ERIK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3630 | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860033630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285229879 | ||||||||
| FaxNumber: | 9285229880 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 CLINIC RD | ||||||||
| Address2: | |||||||||
| City: | GRAND CANYON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286382551 | ||||||||
| FaxNumber: | 9286382598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 09/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 36360 | AZ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | A74666 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 36360 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 418849 | 05 | AZ | MEDICAID |