Provider Demographics
NPI:1013305283
Name:MORTENSEN, BRUCE A (PA)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:A
Last Name:MORTENSEN
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Gender:M
Credentials:PA
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Mailing Address - Street 1:1110 E ROUTE 66 STE 100
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4772
Mailing Address - Country:US
Mailing Address - Phone:928-773-9695
Mailing Address - Fax:928-773-0208
Practice Address - Street 1:2000 S THOMPSON ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-8759
Practice Address - Country:US
Practice Address - Phone:928-226-6400
Practice Address - Fax:928-226-6410
Is Sole Proprietor?:No
Enumeration Date:2014-12-22
Last Update Date:2020-10-26
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant