Provider Demographics
NPI:1376209833
Name:MACHUCA, JENIFFER DIANE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JENIFFER
Middle Name:DIANE
Last Name:MACHUCA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:JENIFFER
Other - Middle Name:DIANE
Other - Last Name:AGUILAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2005 S SERTOMA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-4560
Mailing Address - Country:US
Mailing Address - Phone:480-399-8020
Mailing Address - Fax:
Practice Address - Street 1:3929 E BELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2112
Practice Address - Country:US
Practice Address - Phone:541-789-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9965363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty