Healthcare Provider Details

I. General information

NPI: 1134518079
Provider Name (Legal Business Name): MISS PAIGE FERGEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2015
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E. SOUTHERN AVE. STE 310 SUPPLEMENTAL HEALTHCARE
TEMPE AZ
85282
US

IV. Provider business mailing address

6796 W GREENBRIAR DR
GLENDALE AZ
85308-8440
US

V. Phone/Fax

Practice location:
  • Phone: 866-308-2700
  • Fax:
Mailing address:
  • Phone: 623-332-1504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number10965A
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: