Provider Demographics
NPI:1245690809
Name:COLLABORATIVE MEDICAL PROVIDER GROUP, PLLC
Entity type:Organization
Organization Name:COLLABORATIVE MEDICAL PROVIDER GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:AGINS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:602-867-1302
Mailing Address - Street 1:8300 N WESTCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85743-1043
Mailing Address - Country:US
Mailing Address - Phone:602-867-1302
Mailing Address - Fax:602-867-4247
Practice Address - Street 1:8300 N WESTCLIFF DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85743-1043
Practice Address - Country:US
Practice Address - Phone:602-867-1302
Practice Address - Fax:602-867-4247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2311363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ107888Medicare UPIN