Basic Information
| Provider Information | |||||||||
| NPI: | 1679554430 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUENTEVILLA | ||||||||
| FirstName: | ANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1775 E SKYLINE DR | ||||||||
| Address2: | STE 101 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857181162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206156200 | ||||||||
| FaxNumber: | 5206152655 | ||||||||
| Practice Location | |||||||||
| Address1: | 1775 E SKYLINE DR | ||||||||
| Address2: | STE 101 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857181162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206156200 | ||||||||
| FaxNumber: | 5206152655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 11/25/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 18893 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110643 | 05 | AZ | MEDICAID |