Provider Demographics
NPI:1801864780
Name:HINDE, JACQUELINE J (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:J
Last Name:HINDE
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:PO BOX 1625
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-1625
Mailing Address - Country:US
Mailing Address - Phone:928-645-9675
Mailing Address - Fax:928-645-2626
Practice Address - Street 1:E. ON HWY. 160 TO ROUTE 59
Practice Address - Street 2:BEHIND KAYENTA CHAPTER HOUSE
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033-1496
Practice Address - Country:US
Practice Address - Phone:928-697-8154
Practice Address - Fax:928-697-8559
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2518363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ833493Medicaid
AZ833493Medicaid
AZ77888, 77886Medicare ID - Type Unspecified