Basic Information
| Provider Information | |||||||||
| NPI: | 1932264843 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMMANN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5055 E BROADWAY BLVD | ||||||||
| Address2: | STE A100 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203821205 | ||||||||
| FaxNumber: | 5207950225 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 E LA CANADA, STE 135 | ||||||||
| Address2: | |||||||||
| City: | GREEN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206253230 | ||||||||
| FaxNumber: | 5206259162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2536 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 485767 | 05 | AZ | MEDICAID |