Provider Demographics
NPI:1003817610
Name:CALLIS, JAMES ALTON JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ALTON
Last Name:CALLIS
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JIM
Other - Middle Name:
Other - Last Name:CALLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1625
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-1625
Mailing Address - Country:US
Mailing Address - Phone:928-645-1700
Mailing Address - Fax:928-645-1701
Practice Address - Street 1:3272 E RIO VIRGIN RD
Practice Address - Street 2:
Practice Address - City:LITTLEFIELD
Practice Address - State:AZ
Practice Address - Zip Code:86432-3200
Practice Address - Country:US
Practice Address - Phone:928-347-5971
Practice Address - Fax:928-357-5793
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL15374363A00000X
IDPA529363A00000X
AZ4227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ365217Medicaid
AZ365217Medicaid
ID1666876Medicare PIN
IDQ40862Medicare UPIN
AZZ125021Medicare PIN