Healthcare Provider Details

I. General information

NPI: 1326962101
Provider Name (Legal Business Name): CASA GRANDE FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 N CAMINO MERCADO STE 24
CASA GRANDE AZ
85122-5757
US

IV. Provider business mailing address

580 N CAMINO MERCADO STE 24
CASA GRANDE AZ
85122-5757
US

V. Phone/Fax

Practice location:
  • Phone: 801-310-0819
  • Fax: 801-310-0819
Mailing address:
  • Phone: 801-310-0819
  • Fax: 801-310-0819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: RUSSELL JACKSON
Title or Position: OWNER
Credential: PA
Phone: 801-310-0819