MEDICARE: NORTHERN ARIZONA DERMATOLOGY CENTER PC

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	207N00000X	Dermatology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MICA010529	OTHER	LIABILITY INSURANCE
2	MICA03976	OTHER	LIABILITY INSURANCE
3	295114	OTHER	AHCCCS
4	MICA03876	OTHER	LIABILITY INSURANCE
5	19361	OTHER	AZ LICENSE
6	MICA03874	OTHER	LIABILITY INSURANCE
7	23222	OTHER	AZ LICENSE
8	20368	OTHER	AZ LICENSE
9	MICA03872	OTHER	LIABILITY INSURANCE
10	33121	OTHER	AZ LICENSE
11	25924	OTHER	AZ LICENSE
12	30215	OTHER	AZ LICENSE
13	MICA014013	OTHER	LIABILITY INSURANCE

General Provider Information

NPI Number	:	1962558569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN ARIZONA DERMATOLOGY CENTER PC

Provider Business Mailing Address
First Line	:	1490 N TURQUOISE DR
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001
Country	:	US
Telephone Number	:	928-774-5074
Fax Number	:	928-779-0884

Provider Business Practice Location Address
First Line	:	1490 N TURQUOISE DR
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001
Country	:	US
Telephone Number	:	928-774-5074
Fax Number	:	928-779-0884

Authorized Official
Title or Position	:	CEO
Name	:	DR. SARA JOY RISNER-RUMOHR
Credential	:	MD
Telephone Number	:	928-774-5074

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	05/18/2026

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