Healthcare Provider Details

I. General information

NPI: 1770074676
Provider Name (Legal Business Name): JAMES L PRIDGEN III MSN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20601 N 19TH AVE STE 130
PHOENIX AZ
85027-3587
US

IV. Provider business mailing address

20601 N 19TH AVE STE 130
PHOENIX AZ
85027-3587
US

V. Phone/Fax

Practice location:
  • Phone: 877-564-3627
  • Fax:
Mailing address:
  • Phone: 877-564-3627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN176595
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: