Healthcare Provider Details

I. General information

NPI: 1538725916
Provider Name (Legal Business Name): UTIBE JOSHUA ETUDOR NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2019
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 AINSWORTH DR STE A
PRESCOTT AZ
86301-1623
US

IV. Provider business mailing address

PO BOX 10880
PRESCOTT AZ
86304-0880
US

V. Phone/Fax

Practice location:
  • Phone: 928-771-5548
  • Fax: 928-771-5549
Mailing address:
  • Phone: 602-406-4786
  • Fax: 916-636-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number234106
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: