Provider Demographics
NPI:1679018873
Name:FLAGSTAFF INTENSIVE CARE SPECIALISTS, PLLC
Entity Type:Organization
Organization Name:FLAGSTAFF INTENSIVE CARE SPECIALISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:MAPEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-773-0003
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86002-0967
Mailing Address - Country:US
Mailing Address - Phone:928-773-0003
Mailing Address - Fax:928-773-1170
Practice Address - Street 1:1200 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-773-0003
Practice Address - Fax:928-773-1170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-23
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ247046Medicaid