Provider Demographics
NPI:1467629469
Name:CCENT & FPS
Entity Type:Organization
Organization Name:CCENT & FPS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMARAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:FRATIANNI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-774-1873
Mailing Address - Street 1:1340 N RIM DRIVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1311
Mailing Address - Country:US
Mailing Address - Phone:928-774-1873
Mailing Address - Fax:928-774-5525
Practice Address - Street 1:300 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:LAKESIDE
Practice Address - State:AR
Practice Address - Zip Code:85929-6533
Practice Address - Country:US
Practice Address - Phone:928-774-1873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CCENT & FPS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3000207K00000X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ29952Medicare PIN