Healthcare Provider Details

I. General information

NPI: 1124055637
Provider Name (Legal Business Name): JOHN M. ALTIC PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 S GREENFIELD RD #101
GILBERT AZ
85296-4012
US

IV. Provider business mailing address

888 S GREENFIELD RD #101
GILBERT AZ
85296-4012
US

V. Phone/Fax

Practice location:
  • Phone: 480-892-1300
  • Fax: 480-507-7477
Mailing address:
  • Phone: 480-892-1300
  • Fax: 480-504-7477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2502
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2502
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: