MEDICARE: WESTERN ARIZONA FOOT & ANKLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	0390	AZ

General Provider Information

NPI Number	:	1356535405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN ARIZONA FOOT & ANKLE

Provider Business Mailing Address
First Line	:	1980 MESQUITE AVE
Second Line	:	SUITE 103
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-7713
Country	:	US
Telephone Number	:	928-680-4934
Fax Number	:	928-505-4416

Provider Business Practice Location Address
First Line	:	1980 MESQUITE AVE
Second Line	:	SUITE 103
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-7713
Country	:	US
Telephone Number	:	928-680-4934
Fax Number	:	928-505-4416

Authorized Official
Title or Position	:	OWNER
Name	:	JAMES PATRICK WILSON
Credential	:	DPM
Telephone Number	:	928-680-4934

Provider Enumeration Date	:	08/31/2007
Last Update Date	:	10/10/2007

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Directions to “WESTERN ARIZONA FOOT & ANKLE ” Practice Location

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