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General NPI Number Information
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NPI Number | 1871818492
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Entity Type | Individual
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Provider Name | STACY TALAHYTEWA II RT(R)
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Gender | Male
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Dates
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Enumeration Date | 04/07/2010
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Last Update Date | 04/07/2010
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Provider Practice Location Address
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Address Line | HWY 264 MILE POST 388
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City | POLACCA
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State | AZ
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Zip | 86042
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Country | US
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Telephone | 928-737-6210
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1019
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City | POLACCA
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State | AZ
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Zip | 86042-1019
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Country | US
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Telephone | 928-734-9450
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 247100000X
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Taxonomy Name | Radiologic Technologist
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License Number | CRT-10799
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License Number State | AZ
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