Healthcare Provider Details

I. General information

NPI: 1326635905
Provider Name (Legal Business Name): KAMRAN JAVADI PA-C, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S 6TH ST
WILLIAMS AZ
86046-0110
US

IV. Provider business mailing address

PO BOX 3630
FLAGSTAFF AZ
86003-3630
US

V. Phone/Fax

Practice location:
  • Phone: 928-635-4441
  • Fax:
Mailing address:
  • Phone: 928-522-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9681
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number91664
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: