Basic Information
Provider Information | |||||||||
NPI: | 1710136809 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOGAN | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | JOYCE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CPNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CREAMEN | ||||||||
OtherFirstName: | REBECCA | ||||||||
OtherMiddleName: | JOYCE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7010 E CHAUNCEY LN | ||||||||
Address2: | SUITE 225 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850543117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4805855200 | ||||||||
FaxNumber: | 4805855233 | ||||||||
Practice Location | |||||||||
Address1: | 7010 E CHAUNCEY LN | ||||||||
Address2: | SUITE 225 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850543117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4805855200 | ||||||||
FaxNumber: | 4805855233 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2008 | ||||||||
LastUpdateDate: | 04/20/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 18543 | CA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | AP4317 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 671513 | 05 | AZ |   | MEDICAID |