Provider Demographics
NPI:1164425450
Name:A NEW CREATION WOMENS CLINIC PC
Entity Type:Organization
Organization Name:A NEW CREATION WOMENS CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY-LOUISE
Authorized Official - Middle Name:
Authorized Official - Last Name:MULCAHY
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MBA, BSN
Authorized Official - Phone:480-357-3904
Mailing Address - Street 1:3055 W INA RD
Mailing Address - Street 2:BLDG 12, SUITE 195
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-2107
Mailing Address - Country:US
Mailing Address - Phone:520-293-1117
Mailing Address - Fax:520-293-7701
Practice Address - Street 1:3055 W INA RD
Practice Address - Street 2:BLDG 12, SUITE 195
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-2107
Practice Address - Country:US
Practice Address - Phone:520-293-1117
Practice Address - Fax:520-293-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3090207Q00000X
AZ86363LW0102X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ107905Medicaid
AZ265722Medicaid
AZ425346Medicaid
AZ582363Medicaid
AZ293655Medicaid
AZ429971Medicaid
AZ192914Medicaid
AZ359168Medicaid
AZ429971Medicaid