Provider Demographics
NPI:1003211889
Name:OVALLE, ERIC TOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:TOMAS
Last Name:OVALLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 N DYSART RD
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-1208
Mailing Address - Country:US
Mailing Address - Phone:602-726-8788
Mailing Address - Fax:480-420-0732
Practice Address - Street 1:3125 N DYSART RD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-1208
Practice Address - Country:US
Practice Address - Phone:602-726-8788
Practice Address - Fax:480-420-0732
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5858363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant