=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275614786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY VINIK P.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 02/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 W ST. MARY'S ROAD
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-647-8854
-----------------------------------------------------
Fax | 520-647-8851
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 630 N ALVERNON WAY SUITE 250
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85711-1843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-647-8854
-----------------------------------------------------
Fax | 520-647-8851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 3480
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------