Healthcare Provider Details

I. General information

NPI: 1881776201
Provider Name (Legal Business Name): WILLIAM COLLAZO-NUNEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USA MEDDAC, RWBAHC 2240 E. WINROW AVE., ATTN: MCXJ-CREDENTIALS
FORT HUACHUCA AZ
85613-7079
US

IV. Provider business mailing address

1933 EXETER DR
SIERRA VISTA AZ
85635-4817
US

V. Phone/Fax

Practice location:
  • Phone: 520-599-1696
  • Fax: 520-533-7099
Mailing address:
  • Phone: 520-458-3445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number08209
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number008209
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: