Healthcare Provider Details

I. General information

NPI: 1407820509
Provider Name (Legal Business Name): JURGEN M HALL FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8410 STARDUST TRAIL
FLAGSTAFF AZ
86004
US

IV. Provider business mailing address

8410 STARDUST TRL
FLAGSTAFF AZ
86004-3177
US

V. Phone/Fax

Practice location:
  • Phone: 928-737-6002
  • Fax: 928-737-6001
Mailing address:
  • Phone: 928-527-0062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP1515
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN091549
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: