Provider Demographics
NPI:1598722530
Name:HARTZELL, SALLY A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:A
Last Name:HARTZELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 W. BASELINE RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041
Mailing Address - Country:US
Mailing Address - Phone:480-677-8282
Mailing Address - Fax:480-677-8283
Practice Address - Street 1:2640 W BASELINE RD STE 111
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-6492
Practice Address - Country:US
Practice Address - Phone:480-677-8282
Practice Address - Fax:480-677-8283
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2273363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ68288Medicare ID - Type UnspecifiedMEDICARE NUMBER
AZP47324Medicare UPIN