Basic Information
| Provider Information | |||||||||
| NPI: | 1588866453 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | APACHE JUNCTION PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1075 S IDAHO RD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | APACHE JUNCTION | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852196496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808891234 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1075 S IDAHO RD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | APACHE JUNCTION | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852196496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808891234 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GRADLE | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
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| AuthorizedOfficialTitleorPosition: | CERTIFIED PEDIATRIC NURSE PRACTIONE | ||||||||
| AuthorizedOfficialTelephone: | 4808891234 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CPNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 34596 | AZ | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 27900 | AZ | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 34587 | AZ | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | AP0241 | AZ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | AZ0763370 | 01 | AZ | JB BC ID | OTHER | 088674 | 05 | AZ | MEDICAID | 971409 | 05 | AZ | MEDICAID | F14456 | 05 | AZ | MEDICAID | 524729 | 05 | AZ | MEDICAID | AZ0427690 | 01 | AZ | RL BC ID | OTHER | 907397 | 05 | AZ | MEDICAID |