Basic Information
| Provider Information | |||||||||
| NPI: | 1992294755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERRY | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860043708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287197400 | ||||||||
| FaxNumber: | 9284405399 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860043708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2871974009 | ||||||||
| FaxNumber: | 9284405399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2018 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 213ES0103X | POD-001012 | AZ | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.