MEDICARE: THE AMISTAD CLINIC, PLLC

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	207Q00000X	Family Medicine Physician	AP9557	AZ
2	261QP2300X	Primary Care Clinic/Center	AP9557	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639650898
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE AMISTAD CLINIC, PLLC

Provider Business Mailing Address
First Line	:	100 E 24TH ST STE 3A
Second Line	:
City	:	YUMA
State	:	AZ
Zip	:	85364-8619
Country	:	US
Telephone Number	:	928-750-6410
Fax Number	:	928-750-6433

Provider Business Practice Location Address
First Line	:	100 E 24TH ST STE 3A
Second Line	:
City	:	YUMA
State	:	AZ
Zip	:	85364-8619
Country	:	US
Telephone Number	:	480-773-8569
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	WILLIAM BAUTISTA AMISTAD JR.
Credential	:	FNP-BC
Telephone Number	:	480-773-8569

Provider Enumeration Date	:	08/27/2018
Last Update Date	:	02/24/2025

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