Provider Demographics
NPI:1407859416
Name:VAUGHN-DOTTERER, JEANNETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:
Last Name:VAUGHN-DOTTERER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10097
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85230-0097
Mailing Address - Country:US
Mailing Address - Phone:520-836-3446
Mailing Address - Fax:520-836-8807
Practice Address - Street 1:865 N ARIZOLA RD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-6011
Practice Address - Country:US
Practice Address - Phone:520-836-3446
Practice Address - Fax:520-836-8807
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2896363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q08306Medicare UPIN
78286Medicare ID - Type Unspecified