Provider Demographics
NPI:1275855231
Name:FLACK, JEFFREY ROBERT (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ROBERT
Last Name:FLACK
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 W ELLIOT RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-5102
Mailing Address - Country:US
Mailing Address - Phone:480-214-4466
Mailing Address - Fax:
Practice Address - Street 1:890 W ELLIOT RD
Practice Address - Street 2:SUITE 103
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-5102
Practice Address - Country:US
Practice Address - Phone:480-214-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ00902255A2300X
AZ5473363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer