Basic Information
| Provider Information | |||||||||
| NPI: | 1902804974 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAN | ||||||||
| FirstName: | MINDY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121 N. BEVERLY AVE | ||||||||
| Address2: | STE 105 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857122154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203276265 | ||||||||
| FaxNumber: | 5203279300 | ||||||||
| Practice Location | |||||||||
| Address1: | 1645 N SWAN RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857124046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203276265 | ||||||||
| FaxNumber: | 5203279300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/16/2006 | ||||||||
| NPIReactivationDate: | 03/20/2006 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 33714 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 917958 | 05 | AZ | MEDICAID |