Provider Demographics
NPI:1437452836
Name:ABBOTT, DELMAS LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DELMAS
Middle Name:LEE
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:D. LEE
Other - Middle Name:
Other - Last Name:ABBOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1670 WILLOW CREEK RD STE A
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1112
Mailing Address - Country:US
Mailing Address - Phone:928-255-5191
Mailing Address - Fax:928-316-9703
Practice Address - Street 1:1670 WILLOW CREEK RD STE A
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1112
Practice Address - Country:US
Practice Address - Phone:928-255-5191
Practice Address - Fax:928-316-9703
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087713363A00000X
AZ6154363A00000X, 363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant