Provider Demographics
NPI:1710521901
Name:NORTHERN ARIZONA FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:NORTHERN ARIZONA FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-243-6881
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:AZ
Mailing Address - Zip Code:85939-0339
Mailing Address - Country:US
Mailing Address - Phone:928-243-6881
Mailing Address - Fax:
Practice Address - Street 1:14 E TUMBLEWEED LANE
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:AZ
Practice Address - Zip Code:85939-8593
Practice Address - Country:US
Practice Address - Phone:928-243-6881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ207Q00000XOtherTAXONOMY CODE
AZ579169Medicaid