=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558987644
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEXI TAYLOR KORTSEN OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2020
-----------------------------------------------------
Last Update Date | 05/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 N SAN FRANCISCO ST
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-3236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-779-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 W UNIVERSITY AVE STE 105
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-3154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-240-9214
-----------------------------------------------------
Fax | 928-240-9212
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT-002429
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------