Healthcare Provider Details

I. General information

NPI: 1972034080
Provider Name (Legal Business Name): MICHAEL TOKUNAGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 BRIAR ST
PRESCOTT AZ
86305-5036
US

IV. Provider business mailing address

123 BRIAR ST
PRESCOTT AZ
86305-5036
US

V. Phone/Fax

Practice location:
  • Phone: 928-713-2868
  • Fax:
Mailing address:
  • Phone: 928-713-2868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-15998
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: