Provider Demographics
NPI:1174500581
Name:FORCH, JANIS SUZANN (PA)
Entity Type:Individual
Prefix:
First Name:JANIS
Middle Name:SUZANN
Last Name:FORCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9609
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-9609
Mailing Address - Country:US
Mailing Address - Phone:623-773-2273
Mailing Address - Fax:623-773-2274
Practice Address - Street 1:7615 W THUNDERBIRD RD
Practice Address - Street 2:STE 106
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-6083
Practice Address - Country:US
Practice Address - Phone:623-773-2273
Practice Address - Fax:623-773-2274
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1385363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ173336Medicaid
AZZ141457Medicare PIN