Provider Demographics
NPI:1356535405
Name:WESTERN ARIZONA FOOT & ANKLE
Entity type:Organization
Organization Name:WESTERN ARIZONA FOOT & ANKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:928-680-4934
Mailing Address - Street 1:1980 MESQUITE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-7713
Mailing Address - Country:US
Mailing Address - Phone:928-680-4934
Mailing Address - Fax:928-505-4416
Practice Address - Street 1:1980 MESQUITE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-7713
Practice Address - Country:US
Practice Address - Phone:928-680-4934
Practice Address - Fax:928-505-4416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0390213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ156796Medicare PIN
AZU37942Medicare UPIN
AZZ77509Medicare PIN