Provider Demographics
NPI:1578965067
Name:ALFORD, REGAN R (PAC)
Entity Type:Individual
Prefix:
First Name:REGAN
Middle Name:R
Last Name:ALFORD
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7587
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85011-7587
Mailing Address - Country:US
Mailing Address - Phone:602-258-4788
Mailing Address - Fax:602-258-5131
Practice Address - Street 1:370 E VIRGINIA AVE
Practice Address - Street 2:STE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1214
Practice Address - Country:US
Practice Address - Phone:602-258-4788
Practice Address - Fax:602-258-5131
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5805363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ953346Medicaid
AZ953346Medicaid