Basic Information
| Provider Information | |||||||||
| NPI: | 1629064613 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONQUIST | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | RALPH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3815 E BELL RD STE 2200 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026333838 | ||||||||
| FaxNumber: | 6026333845 | ||||||||
| Practice Location | |||||||||
| Address1: | 13555 W MCDOWELL RD | ||||||||
| Address2: | #103 | ||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239251157 | ||||||||
| FaxNumber: | 6239321045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 22778 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 188210 | 01 | AZ | AHCCCS | OTHER |