Provider Demographics
NPI:1063490316
Name:BLACK, FARRAH L (PA)
Entity Type:Individual
Prefix:MISS
First Name:FARRAH
Middle Name:L
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1300 N 12TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2848
Mailing Address - Country:US
Mailing Address - Phone:602-839-2606
Mailing Address - Fax:602-839-4123
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:STE 500
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-839-2606
Practice Address - Fax:602-839-4123
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2012-10-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ2874363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ803305Medicaid
AZ803305Medicaid