Provider Demographics
NPI:1417348244
Name:ABCORE FAMILY PRACTICE
Entity Type:Organization
Organization Name:ABCORE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:623-419-2799
Mailing Address - Street 1:5336 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2944
Mailing Address - Country:US
Mailing Address - Phone:623-419-2799
Mailing Address - Fax:602-358-7649
Practice Address - Street 1:5336 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2944
Practice Address - Country:US
Practice Address - Phone:623-419-2799
Practice Address - Fax:602-358-7649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-16
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7356363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ013638Medicaid
AZ1326477134OtherNPI
AZ1326477134OtherNPI