Provider Demographics
NPI:1487010518
Name:LEGACY PRIMARY HEALTHCARE
Entity Type:Organization
Organization Name:LEGACY PRIMARY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMEELA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMEEN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:520-971-7781
Mailing Address - Street 1:7202 W ROMERO POOLS PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85743-5540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77 CALLE PORTAL STE B260A
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2998
Practice Address - Country:US
Practice Address - Phone:520-226-4338
Practice Address - Fax:866-337-8432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4903363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ803226Medicaid