Provider Demographics
NPI:1689744674
Name:BLACK, DEBORAH L (PA-C)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:L
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:L
Other - Last Name:ABBOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2016 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-4026
Mailing Address - Country:US
Mailing Address - Phone:928-428-1377
Mailing Address - Fax:928-348-8570
Practice Address - Street 1:2016 W 16TH ST
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-4026
Practice Address - Country:US
Practice Address - Phone:928-428-1377
Practice Address - Fax:928-348-8570
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2394363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ636631Medicaid
AZP44241Medicare UPIN
AZ636631Medicaid