Healthcare Provider Details

I. General information

NPI: 1962474361
Provider Name (Legal Business Name): GEORGE J JICHA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 08/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E FLORENCE BLVD
CASA GRANDE AZ
85222-5303
US

IV. Provider business mailing address

6653 MAIN STREET THE EXIGENCE GROUP C O JANENE FARLEY
WILLIAMSVILLE NY
14221
US

V. Phone/Fax

Practice location:
  • Phone: 520-381-6300
  • Fax: 520-381-6618
Mailing address:
  • Phone: 716-817-2932
  • Fax: 716-204-4501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2388
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: