Healthcare Provider Details

I. General information

NPI: 1871582635
Provider Name (Legal Business Name): MARY CATHERINE PORVAZNIK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S YALE ST STE 2
FLAGSTAFF AZ
86001-7304
US

IV. Provider business mailing address

1501 S YALE ST STE 2
FLAGSTAFF AZ
86001-7304
US

V. Phone/Fax

Practice location:
  • Phone: 928-527-4325
  • Fax: 928-527-4327
Mailing address:
  • Phone: 928-527-4325
  • Fax: 928-527-4327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22035
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: