Provider Demographics
NPI:1972014900
Name:JAMA, FARTUN A
Entity Type:Individual
Prefix:
First Name:FARTUN
Middle Name:A
Last Name:JAMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6123
Mailing Address - Country:US
Mailing Address - Phone:928-819-8999
Mailing Address - Fax:
Practice Address - Street 1:815 E JUAN SANCHEZ BLVD
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-627-3822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6792363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ321252Medicaid