Provider Demographics
NPI:1750466249
Name:FAZ, MIKE DANNY (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:DANNY
Last Name:FAZ
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 ZORENA AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5688
Mailing Address - Country:US
Mailing Address - Phone:928-729-8805
Mailing Address - Fax:928-729-8814
Practice Address - Street 1:CORNER OF ROUTE N12 AND N7
Practice Address - Street 2:FORT DEFIANCE PHS HOSPITAL
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8805
Practice Address - Fax:928-729-8814
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4295021225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000T5129Medicaid
AZ779803Medicaid