Provider Demographics
NPI:1376798421
Name:BLACK, IAIN ALAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:IAIN
Middle Name:ALAN
Last Name:BLACK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13943 N. 91ST AVE, BUILDING I
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-3692
Mailing Address - Country:US
Mailing Address - Phone:623-815-2690
Mailing Address - Fax:623-815-2689
Practice Address - Street 1:13943 N 91ST AVE
Practice Address - Street 2:BUILDING I
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3629
Practice Address - Country:US
Practice Address - Phone:623-815-2690
Practice Address - Fax:623-815-2689
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4339363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant