Healthcare Provider Details

I. General information

NPI: 1053650416
Provider Name (Legal Business Name): JUVY ESCALANTE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3269 N STOCKTON HILL RD
KINGMAN AZ
86409-3619
US

IV. Provider business mailing address

PO BOX 4325
OCEANSIDE CA
92052-4325
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-2101
  • Fax:
Mailing address:
  • Phone: 760-473-0444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberPA 21502
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10524
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: