Provider Demographics
NPI:1245762491
Name:SYCAMORE AVENUE MEDICAL CENTER, PLLC
Entity Type:Organization
Organization Name:SYCAMORE AVENUE MEDICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MURRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-692-1900
Mailing Address - Street 1:975 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3548
Mailing Address - Country:US
Mailing Address - Phone:928-692-1900
Mailing Address - Fax:928-681-1922
Practice Address - Street 1:975 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3548
Practice Address - Country:US
Practice Address - Phone:928-692-1900
Practice Address - Fax:928-681-1922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-28
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3349363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty