MEDICARE: DR. JAMES G STAFFNIK MA EDD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	15470
2	103TS0200X	School Psychologist		AZ

General Provider Information

NPI Number	:	1205963782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES G STAFFNIK MA EDD

Provider Business Mailing Address
First Line	:	PO BOX 546
Second Line	:
City	:	CONCHO
State	:	AZ
Zip	:	85924
Country	:	US
Telephone Number	:	928-337-2279
Fax Number	:	928-337-3526

Provider Business Practice Location Address
First Line	:	450 SOUTH 13TH WEST
Second Line	:	ST JOHNS USD
City	:	ST JOHN
State	:	AZ
Zip	:	85936
Country	:	US
Telephone Number	:	928-337-2279
Fax Number	:	928-337-3526

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	07/26/2007

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