Provider Demographics
NPI:1619211935
Name:PAYNE, MICHAEL ERIC (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERIC
Last Name:PAYNE
Suffix:
Gender:M
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 1:500 W. THOMAS ROAD, SUITE 850
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013
Mailing Address - Country:US
Mailing Address - Phone:602-406-2665
Mailing Address - Fax:602-212-4768
Practice Address - Street 1:500 W. THOMAS ROAD, SUITE 850
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013
Practice Address - Country:US
Practice Address - Phone:602-406-2669
Practice Address - Fax:602-406-6889
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5267363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ763691Medicaid
AZ5267OtherARIZONA STATE BOARD LICENSE
AZ763691Medicaid