Basic Information
| Provider Information | |||||||||
| NPI: | 1740432921 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OVERLY | ||||||||
| FirstName: | BRITA | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | PA-C | ||||||||
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| 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 CHAUNCEY LN | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | PHOENOX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850543117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805855200 | ||||||||
| FaxNumber: | 4805855233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2008 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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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 | 363AM0700X | 4297 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 4207 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 593232 | 05 | AZ | MEDICAID |