Basic Information
| Provider Information | |||||||||
| NPI: | 1710994884 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMURRAY | ||||||||
| FirstName: | BERKELY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OLVERA | ||||||||
| OtherFirstName: | BERKEY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 N BEAVER ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282136235 | ||||||||
| FaxNumber: | 9282136292 | ||||||||
| Practice Location | |||||||||
| Address1: | 167 NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | TUBA CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282832094 | ||||||||
| FaxNumber: | 9282832677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | CP000619 | SD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | AP4122 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | AP4122 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 799080 | 05 | AZ | MEDICAID |