Provider Demographics
NPI:1497867683
Name:JACOVINI, CARRIE (PA C)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:JACOVINI
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:HAAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7194 W MOHAWK LANE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308
Mailing Address - Country:US
Mailing Address - Phone:623-376-0760
Mailing Address - Fax:
Practice Address - Street 1:18589 N 59TH AVE
Practice Address - Street 2:STE 101
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:480-776-1588
Practice Address - Fax:602-547-8700
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2312363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ748600Medicaid
P15132Medicare UPIN