Healthcare Provider Details

I. General information

NPI: 1154453728
Provider Name (Legal Business Name): PINETOP MEDICAL ASSOCIATES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 05/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 E WHITE MOUNTAIN BLVD SUITE A
PINETOP AZ
85935-7027
US

IV. Provider business mailing address

PO BOX 2690
PINETOP AZ
85935-2690
US

V. Phone/Fax

Practice location:
  • Phone: 928-367-6688
  • Fax: 938-367-4916
Mailing address:
  • Phone: 928-367-6688
  • Fax: 928-367-4916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2577
License Number StateAZ

VIII. Authorized Official

Name: THOMAS S PAXMAN
Title or Position: OWNER
Credential: DO
Phone: 928-367-6688