Healthcare Provider Details

I. General information

NPI: 1720110984
Provider Name (Legal Business Name): PRESCOTT GASTROENTEROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 AINSWORTH DR STE 103
PRESCOTT AZ
86301-1687
US

IV. Provider business mailing address

811 AINSWORTH DR STE 103
PRESCOTT AZ
86301-1687
US

V. Phone/Fax

Practice location:
  • Phone: 928-771-5548
  • Fax: 928-771-5549
Mailing address:
  • Phone: 928-771-5548
  • Fax: 928-771-5549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number22747
License Number StateAZ

VIII. Authorized Official

Name: MRS. DEBBIE MARIE DE LUNA
Title or Position: OFFICE MANAGER
Credential:
Phone: 928-771-5548