Provider Demographics
NPI:1093263188
Name:PATRIOT INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:PATRIOT INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HELENE
Authorized Official - Middle Name:P
Authorized Official - Last Name:HENAGER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:520-398-7079
Mailing Address - Street 1:9356 E RITA RD
Mailing Address - Street 2:STE 140
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85747-6315
Mailing Address - Country:US
Mailing Address - Phone:520-398-7079
Mailing Address - Fax:520-207-4317
Practice Address - Street 1:9356 E RITA RD
Practice Address - Street 2:STE 140
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85747-6315
Practice Address - Country:US
Practice Address - Phone:520-398-7079
Practice Address - Fax:520-207-4317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-17
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ241716Medicaid
AZ241716Medicaid