Healthcare Provider Details

I. General information

NPI: 1467629469
Provider Name (Legal Business Name): CCENT & FPS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W WHITE MOUNTAIN BLVD SUITE D
LAKESIDE AR
85929-6533
US

IV. Provider business mailing address

1340 N RIM DRIVE
FLAGSTAFF AZ
86001-1311
US

V. Phone/Fax

Practice location:
  • Phone: 928-774-1873
  • Fax:
Mailing address:
  • Phone: 928-774-1873
  • Fax: 928-774-5525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number3000
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number3000
License Number StateAZ

VIII. Authorized Official

Name: DR. TAMARAH A FRATIANNI
Title or Position: PHYSICIAN
Credential: D.O
Phone: 928-774-1873