Provider Demographics
NPI:1821090846
Name:SHARP, NANNETTE (PA)
Entity Type:Individual
Prefix:
First Name:NANNETTE
Middle Name:
Last Name:SHARP
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 MESQUITE AVE
Mailing Address - Street 2:STE B
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5771
Mailing Address - Country:US
Mailing Address - Phone:928-453-8500
Mailing Address - Fax:928-453-5556
Practice Address - Street 1:1840 MESQUITE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5771
Practice Address - Country:US
Practice Address - Phone:928-453-8500
Practice Address - Fax:928-453-3660
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1304363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1198420002Medicare NSC
AZZ22901Medicare PIN