Healthcare Provider Details

I. General information

NPI: 1376209833
Provider Name (Legal Business Name): JENIFFER DIANE MACHUCA PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENIFFER DIANE AGUILAR

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 04/06/2024
Certification Date: 04/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3929 E BELL RD
PHOENIX AZ
85032-2112
US

IV. Provider business mailing address

2005 S SERTOMA AVE
SIOUX FALLS SD
57106-4560
US

V. Phone/Fax

Practice location:
  • Phone: 541-789-7000
  • Fax:
Mailing address:
  • Phone: 480-399-8020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9965
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: