Healthcare Provider Details

I. General information

NPI: 1417130949
Provider Name (Legal Business Name): PROFESSIONAL PATHOLOGY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

1050 N SAN FRANCISCO ST STE D
FLAGSTAFF AZ
86001-3259
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-3366
  • Fax:
Mailing address:
  • Phone: 928-774-1693
  • Fax: 928-774-3533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number20030
License Number StateAZ

VIII. Authorized Official

Name: ISABELL E SPEER
Title or Position: OWNER
Credential:
Phone: 928-774-1693