Provider Demographics
NPI:1801864707
Name:WOUNDED FACE, BILLIE JO (PA-C)
Entity Type:Individual
Prefix:
First Name:BILLIE
Middle Name:JO
Last Name:WOUNDED FACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S AVE A
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7127
Mailing Address - Country:US
Mailing Address - Phone:701-421-7538
Mailing Address - Fax:928-336-7508
Practice Address - Street 1:2400 S AVE A
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7127
Practice Address - Country:US
Practice Address - Phone:701-421-7538
Practice Address - Fax:928-336-7508
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2676363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ329434Medicaid
AZ106827Medicare ID - Type Unspecified
AZS10929Medicare UPIN