Provider Demographics
NPI:1205018678
Name:IVEY, NATASHA L (PA-C)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:L
Last Name:IVEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746093
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6093
Mailing Address - Country:US
Mailing Address - Phone:773-759-7550
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:6052 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-7709
Practice Address - Country:US
Practice Address - Phone:480-618-0176
Practice Address - Fax:623-632-0129
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ4401363AM0700X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50074903OtherCAPITAL BLUE CROSS
PA232809429021OtherTRICARE
PA50074903OtherCAPITAL BLUE CROSS