Provider Demographics
NPI:1639650898
Name:THE AMISTAD CLINIC, PLLC
Entity Type:Organization
Organization Name:THE AMISTAD CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BAUTISTA
Authorized Official - Last Name:AMISTAD
Authorized Official - Suffix:JR
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:480-773-8569
Mailing Address - Street 1:100 E 24TH ST STE 3A
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8619
Mailing Address - Country:US
Mailing Address - Phone:928-750-6410
Mailing Address - Fax:928-750-6433
Practice Address - Street 1:100 E 24TH ST STE 3A
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8619
Practice Address - Country:US
Practice Address - Phone:773-230-9645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-27
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP9557207Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ205215Medicaid