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General NPI Number Information
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NPI Number | 1639650898
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Entity Type | Organization
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Legal Business Name | THE AMISTAD CLINIC, PLLC
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Dates
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Enumeration Date | 08/27/2018
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Last Update Date | 02/24/2025
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Provider Practice Location Address
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Address Line | 100 E 24TH ST STE 3A
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City | YUMA
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State | AZ
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Zip | 85364-8619
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Country | US
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Telephone | 480-773-8569
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Fax |
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Provider Business Mailing Address
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Address Line | 100 E 24TH ST STE 3A
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City | YUMA
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State | AZ
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Zip | 85364-8619
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Country | US
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Telephone | 928-750-6410
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Fax | 928-750-6433
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Authorized Official
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Title or Position | PROVIDER
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Name | WILLIAM BAUTISTA AMISTAD JR.
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Credential | FNP-BC
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Telephone | 480-773-8569
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | AP9557
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | AP9557
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License Number State | AZ
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