Healthcare Provider Details

I. General information

NPI: 1750431029
Provider Name (Legal Business Name): JAMIE M CONKLIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1641 E GUADALUPE RD
GILBERT AZ
85234-8168
US

IV. Provider business mailing address

1250 S CLEARVIEW AVE SUITE 100
MESA AZ
85209-3378
US

V. Phone/Fax

Practice location:
  • Phone: 480-813-4233
  • Fax: 480-813-4490
Mailing address:
  • Phone: 480-988-9108
  • Fax: 480-813-4460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5551
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: