Healthcare Provider Details

I. General information

NPI: 1295725067
Provider Name (Legal Business Name): ARCHIE M KINNEY PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WEST HOSPITAL DRIVE
WHITERIVER AZ
85941-0860
US

IV. Provider business mailing address

PO BOX 860 WHITERIVER INDIAN HOSPITAL
WHITERIVER AZ
85941-0860
US

V. Phone/Fax

Practice location:
  • Phone: 928-338-4911
  • Fax: 928-338-1122
Mailing address:
  • Phone: 928-338-4911
  • Fax: 928-338-1122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1148
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: