Basic Information
Provider Information | |||||||||
NPI: | 1750466249 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FAZ | ||||||||
FirstName: | MIKE | ||||||||
MiddleName: | DANNY | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHYSICAL THERAPIST | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 402 ZORENA AVE | ||||||||
Address2: |   | ||||||||
City: | GALLUP | ||||||||
State: | NM | ||||||||
PostalCode: | 873015688 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287298805 | ||||||||
FaxNumber: | 9287298814 | ||||||||
Practice Location | |||||||||
Address1: | CORNER OF ROUTE N12 AND N7 | ||||||||
Address2: | FORT DEFIANCE PHS HOSPITAL | ||||||||
City: | FORT DEFIANCE | ||||||||
State: | AZ | ||||||||
PostalCode: | 86504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287298805 | ||||||||
FaxNumber: | 9287298814 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4295021 | AZ | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 000T5129 | 05 | NM |   | MEDICAID | 779803 | 05 | AZ |   | MEDICAID |