Provider Demographics
NPI:1275530552
Name:VAN ATTA, ROGER A (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:A
Last Name:VAN ATTA
Suffix:
Gender:M
Credentials:MD
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 29211
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9211
Mailing Address - Country:US
Mailing Address - Phone:602-273-6770
Mailing Address - Fax:602-889-0489
Practice Address - Street 1:1003 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1641
Practice Address - Country:US
Practice Address - Phone:602-273-6770
Practice Address - Fax:602-889-0489
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8627207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ109505Medicare PIN
AZD44594Medicare UPIN