Provider Demographics
NPI:1407495286
Name:PROFESSIONAL NATURAL MEDICAL
Entity Type:Organization
Organization Name:PROFESSIONAL NATURAL MEDICAL
Other - Org Name:PROFESSIONAL NATURAL MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:NMD
Authorized Official - Phone:480-322-8577
Mailing Address - Street 1:NICKJOHNSON369021@OUTLOOK.COM
Mailing Address - Street 2:1432 W. BIRCH RD
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140
Mailing Address - Country:US
Mailing Address - Phone:480-322-8577
Mailing Address - Fax:
Practice Address - Street 1:9700 N 91ST ST STE A115
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5036
Practice Address - Country:US
Practice Address - Phone:480-322-8577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-27
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ495858Medicaid