Healthcare Provider Details

I. General information

NPI: 1588866453
Provider Name (Legal Business Name): APACHE JUNCTION PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 S IDAHO RD SUITE 206
APACHE JUNCTION AZ
85219-6496
US

IV. Provider business mailing address

1075 S IDAHO RD SUITE 206
APACHE JUNCTION AZ
85219-6496
US

V. Phone/Fax

Practice location:
  • Phone: 480-889-1234
  • Fax:
Mailing address:
  • Phone: 480-889-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34596
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27900
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34587
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAP0241
License Number StateAZ

VIII. Authorized Official

Name: MRS. JANET GRADLE
Title or Position: CERTIFIED PEDIATRIC NURSE PRACTIONE
Credential: CPNP
Phone: 480-889-1234