Provider Demographics
NPI:1205042223
Name:KINGMAN NEUROLOGY
Entity Type:Organization
Organization Name:KINGMAN NEUROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NIMFA
Authorized Official - Middle Name:R
Authorized Official - Last Name:AGUILA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-681-8288
Mailing Address - Street 1:1730 E BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3500
Mailing Address - Country:US
Mailing Address - Phone:928-681-8288
Mailing Address - Fax:928-681-8289
Practice Address - Street 1:1730 E BEVERLY AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3500
Practice Address - Country:US
Practice Address - Phone:928-681-8288
Practice Address - Fax:928-681-8289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32057174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ816001Medicaid
AZ816001Medicaid