Provider Demographics
NPI:1306866892
Name:HARRIETT, ROSALYN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ROSALYN
Middle Name:
Last Name:HARRIETT
Suffix:
Gender:F
Credentials:PA-C
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 1625
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-1625
Mailing Address - Country:US
Mailing Address - Phone:928-645-9675
Mailing Address - Fax:928-645-2626
Practice Address - Street 1:227 MAIN ST.
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:AZ
Practice Address - Zip Code:85534
Practice Address - Country:US
Practice Address - Phone:928-359-1380
Practice Address - Fax:928-359-1381
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2817363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ845042Medicaid
AZS10914Medicare UPIN
AZ77956Medicare PIN