MEDICARE: WOMEN CLINIC OF NORTHERN ARIZONA

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	207V00000X	Obstetrics & Gynecology Physician	22985	AZ

General Provider Information

NPI Number	:	1780917369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOMEN CLINIC OF NORTHERN ARIZONA

Provider Business Mailing Address
First Line	:	1024 N SAN FRANCISCO ST STE 105
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-3266
Country	:	US
Telephone Number	:	928-779-0341
Fax Number	:	928-774-4994

Provider Business Practice Location Address
First Line	:	1024 N SAN FRANCISCO ST STE 105
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-3266
Country	:	US
Telephone Number	:	928-779-0341
Fax Number	:	928-774-4994

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	JAN O SHIELS
Credential	:	MD
Telephone Number	:	928-779-0341

Provider Enumeration Date	:	09/14/2009
Last Update Date	:	09/14/2009

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