Provider Demographics
NPI:1669865408
Name:SJ MEDICAL GROUP
Entity Type:Organization
Organization Name:SJ MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:IMMACULATA
Authorized Official - Middle Name:
Authorized Official - Last Name:INYANG
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:602-753-0667
Mailing Address - Street 1:4622 N 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-3403
Mailing Address - Country:US
Mailing Address - Phone:602-753-0667
Mailing Address - Fax:602-441-2202
Practice Address - Street 1:4622 N 35TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-3403
Practice Address - Country:US
Practice Address - Phone:602-753-0667
Practice Address - Fax:602-441-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7650363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty