Provider Demographics
NPI:1558927921
Name:TAG MEDICAL & STAFFING
Entity Type:Organization
Organization Name:TAG MEDICAL & STAFFING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICIAN ASSISTANT
Authorized Official - Phone:254-931-8298
Mailing Address - Street 1:2371 E AZALEA DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-2365
Mailing Address - Country:US
Mailing Address - Phone:254-931-8298
Mailing Address - Fax:
Practice Address - Street 1:2601 N 3RD ST STE 106
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1144
Practice Address - Country:US
Practice Address - Phone:254-931-8298
Practice Address - Fax:602-248-8006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-11
Last Update Date:2019-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2124OtherSTATE LICENSE
1035995OtherNCCPA