FORTNEY, RICHARD (PA)

Provider Demographics

• NPI: 1376563999
• Name: FORTNEY, RICHARD (PA)
• Entity Type: Individual
• First Name: RICHARD
• Last Name: FORTNEY
• Gender: M
• Credentials: PA
• Mailing Address - Street 1: 2060 W 24TH ST
• Mailing Address - City: YUMA
• Mailing Address - State: AZ
• Mailing Address - Zip Code: 85364-6123
• Mailing Address - Country: US
• Mailing Address - Phone: 928-539-3082
• Mailing Address - Fax: 928-539-5579
• Practice Address - Street 1: 2060 W 24TH ST
• Practice Address - City: YUMA
• Practice Address - State: AZ
• Practice Address - Zip Code: 85364-6123
• Practice Address - Country: US
• Practice Address - Phone: 928-539-3082
• Practice Address - Fax: 928-539-5579
• Is Sole Proprietor?: No
• Enumeration Date: 2006-07-19
• Last Update Date: 2014-02-24

Provider Licenses

State	License ID	Taxonomies
AZ	1549	363A00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant

Provider Identifiers

State	Identifier ID	ID Type	Issuer
	1043324932	Other	CLINIC NPI
	1245344316	Other	CLINIC NPI
	1063433720	Other	CLINIC NPI
	1962507376	Other	CLINIC NPI
AZ	162355	Medicaid
AZ	Z21114	Medicare PIN
AZ	Z21130	Medicare PIN
	1245344316	Other	CLINIC NPI
	1043324932	Other	CLINIC NPI
	031824	Medicare Oscar/Certification
AZ	162355	Medicaid
	031823	Medicare Oscar/Certification
	031805	Medicare Oscar/Certification
AZ	Z21113	Medicare PIN
	031822	Medicare Oscar/Certification
	031822	Medicare Oscar/Certification