Provider Demographics
NPI:1962470963
Name:MOTTER, ALAN W (FNP -C)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:W
Last Name:MOTTER
Suffix:
Gender:M
Credentials:FNP -C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 E ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4771
Mailing Address - Country:US
Mailing Address - Phone:928-773-9695
Mailing Address - Fax:928-772-0208
Practice Address - Street 1:1110 E ROUTE 66
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4771
Practice Address - Country:US
Practice Address - Phone:928-773-9695
Practice Address - Fax:928-772-0208
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN076694163W00000X
AZAZ AP 2229363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ00640Medicaid
AZZ122305Medicare PIN