Basic Information
| Provider Information | |||||||||
| NPI: | 1801864780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HINDE | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1625 | ||||||||
| Address2: | |||||||||
| City: | PAGE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860401625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286459675 | ||||||||
| FaxNumber: | 9286452626 | ||||||||
| Practice Location | |||||||||
| Address1: | E. ON HWY. 160 TO ROUTE 59 | ||||||||
| Address2: | BEHIND KAYENTA CHAPTER HOUSE | ||||||||
| City: | KAYENTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860331496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286978154 | ||||||||
| FaxNumber: | 9286978559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 2518 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 833493 | 05 | AZ | MEDICAID |