=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790296853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COPPER VALLEY PRIMARY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2017
-----------------------------------------------------
Last Update Date | 07/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7290 E BROADWAY BLVD STE 178
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85710-0412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-306-7717
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7290 E BROADWAY BLVD STE 142
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85710-0410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-207-3913
-----------------------------------------------------
Fax | 520-207-5451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APN
-----------------------------------------------------
Name | LAURA MONCADA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-207-3913
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP7797
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------