Provider Demographics
NPI:1396017661
Name:PROFESSIONAL PA-C SERVICES, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL PA-C SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PRESTON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:801-369-4800
Mailing Address - Street 1:24298 S 199TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-3336
Mailing Address - Country:US
Mailing Address - Phone:801-369-4800
Mailing Address - Fax:480-248-9011
Practice Address - Street 1:1800 E FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5303
Practice Address - Country:US
Practice Address - Phone:801-369-4800
Practice Address - Fax:480-248-9011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4317363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty