Provider Demographics
NPI:1942395314
Name:CHURCHILL, PATRICE M (DO)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:M
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:DO
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 10097
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85130-0020
Mailing Address - Country:US
Mailing Address - Phone:520-836-3446
Mailing Address - Fax:520-836-8807
Practice Address - Street 1:174 W HIGHWAY 287
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85132
Practice Address - Country:US
Practice Address - Phone:520-868-5811
Practice Address - Fax:520-868-1223
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ005146207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ398605Medicaid
AZZ127426Medicare PIN
AZ398605Medicaid