Healthcare Provider Details

I. General information

NPI: 1720480312
Provider Name (Legal Business Name): SONOITA SAGE CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3123 ARIZONA HWY 83 B
SONOITA AZ
85637
US

IV. Provider business mailing address

PO BOX 843
SONOITA AZ
85637-0843
US

V. Phone/Fax

Practice location:
  • Phone: 520-415-0330
  • Fax:
Mailing address:
  • Phone: 520-415-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberAP6266
License Number StateAZ

VIII. Authorized Official

Name: MRS. ELAINE MARIAN HOOPER
Title or Position: MEDICAL DIRECTOR
Credential: ANP/GNP, BC
Phone: 520-415-0330