Provider Demographics
NPI:1689645467
Name:NASTERNAK, ABBY MICHELE (PA C)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:MICHELE
Last Name:NASTERNAK
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:ABBY
Other - Middle Name:MICHELE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA C
Mailing Address - Street 1:2550 N THUNDERBIRD CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-1214
Mailing Address - Country:US
Mailing Address - Phone:480-353-2235
Mailing Address - Fax:480-776-0025
Practice Address - Street 1:9494 W NORTHERN AVE
Practice Address - Street 2:101
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-1118
Practice Address - Country:US
Practice Address - Phone:623-872-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3033363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ885048Medicaid
AZ885048Medicaid
AZZ84804Medicare PIN