Basic Information
| Provider Information | |||||||||
| NPI: | 1639174915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOLLERTON | ||||||||
| FirstName: | JOANNE | ||||||||
| MiddleName: | ROSALYN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX PH | ||||||||
| Address2: | |||||||||
| City: | CHINLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 865038000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747001 | ||||||||
| FaxNumber: | 9286747008 | ||||||||
| Practice Location | |||||||||
| Address1: | U.S. 191 & HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | CHINLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 865038000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747001 | ||||||||
| FaxNumber: | 9286747008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 78395 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD19261 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 55167 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 072368 | 05 | OR | MEDICAID |