Provider Demographics
NPI:1871818492
Name:TALAHYTEWA, STACY II (RT(R))
Entity Type:Individual
Prefix:MR
First Name:STACY
Middle Name:
Last Name:TALAHYTEWA
Suffix:II
Gender:M
Credentials:RT(R)
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 1019
Mailing Address - Street 2:
Mailing Address - City:POLACCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86042-1019
Mailing Address - Country:US
Mailing Address - Phone:928-734-9450
Mailing Address - Fax:
Practice Address - Street 1:HWY 264 MILE POST 388
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042
Practice Address - Country:US
Practice Address - Phone:928-737-6210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRT-10799247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist