=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013151323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN C LINCOLN , LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2009
-----------------------------------------------------
Last Update Date | 06/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5859 W TALAVI BLVD SUITE 165
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85306-1869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-548-7800
-----------------------------------------------------
Fax | 602-548-0006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5859 W TALAVI BLVD SUITE 165
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85306-1869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-548-7800
-----------------------------------------------------
Fax | 602-548-0006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. NATHAN ANSPACH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-548-7800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 3316
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 3010
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------