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General NPI Number Information
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NPI Number | 1124243688
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Entity Type | Organization
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Legal Business Name | PONDEROSA PEDIATRICSS PLC
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Dates
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Enumeration Date | 04/17/2007
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Last Update Date | 05/15/2008
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Provider Practice Location Address
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Address Line | 2120 CENTERPOINTE WEST DRIVE
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City | PRESCOTT
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State | AZ
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Zip | 86301
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Country | US
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Telephone | 928-443-1111
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Fax | 928-443-5554
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Provider Business Mailing Address
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Address Line | 2120 CENTERPOINTE WEST DRIVE
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City | PRESCOTT
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State | AZ
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Zip | 86301
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Country | US
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Telephone | 928-443-1111
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Fax | 928-443-5554
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Authorized Official
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Title or Position | CREDENTIALING BILLING
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Name | DEANN HARGUESS
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Credential |
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Telephone | 928-443-1111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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