MEDICARE: BIG PARK FAMILY PRACTICE PC

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	363LF0000X	Family Nurse Practitioner	AP2648	AZ

General Provider Information

NPI Number	:	1902000763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIG PARK FAMILY PRACTICE PC

Provider Business Mailing Address
First Line	:	PO BOX 21540
Second Line	:
City	:	SEDONA
State	:	AZ
Zip	:	86341-1540
Country	:	US
Telephone Number	:	928-300-4783
Fax Number	:	928-634-0337

Provider Business Practice Location Address
First Line	:	61 BELL ROCK PLZ
Second Line	:
City	:	SEDONA
State	:	AZ
Zip	:	86351-8810
Country	:	US
Telephone Number	:	928-300-4783
Fax Number	:	928-634-0337

Authorized Official
Title or Position	:	OWNER
Name	:	TY MONTGOMERY
Credential	:	NP
Telephone Number	:	928-300-4783

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	11/07/2007

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