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General NPI Number Information
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NPI Number | 1053504225
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Entity Type | Organization
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Legal Business Name | LONE WOLF MEDICINE, INC
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Dates
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Enumeration Date | 08/21/2007
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Last Update Date | 08/21/2007
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Provider Practice Location Address
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Address Line | 806 S PONDEROSA ST
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City | PAYSON
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State | AZ
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Zip | 85541-5541
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Country | US
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Telephone | 928-474-6617
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Fax | 928-474-7059
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Provider Business Mailing Address
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Address Line | PO BOX 1670
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City | PAYSON
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State | AZ
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Zip | 85547-1670
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Country | US
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Telephone | 928-474-6617
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Fax | 928-474-7059
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Authorized Official
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Title or Position | PHYSICIAN ASSISITANT
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Name | MARILYN F HERON
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Credential | PAC
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Telephone | 928-474-6617
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 1454
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License Number State | AZ
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