Healthcare Provider Details

I. General information

NPI: 1669960365
Provider Name (Legal Business Name): JOSHUA MICHAEL WALLENTIN-FLORES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOSHUA MICHAEL WALLENTIN-FLORES

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E OAK AVE
FLAGSTAFF AZ
86001-1818
US

IV. Provider business mailing address

504 W FIR AVE
FLAGSTAFF AZ
86001-1309
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-7880
  • Fax:
Mailing address:
  • Phone: 928-853-9293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number73668
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number31485
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number68056
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: