Provider Demographics
NPI:1457800302
Name:DERY-CHAFFIN, JUNIPER (PA-C)
Entity Type:Individual
Prefix:
First Name:JUNIPER
Middle Name:
Last Name:DERY-CHAFFIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 E SARAGOSA ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-6386
Mailing Address - Country:US
Mailing Address - Phone:520-465-7259
Mailing Address - Fax:
Practice Address - Street 1:1515 E OSBORN RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5309
Practice Address - Country:US
Practice Address - Phone:602-604-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6500363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6500OtherSTATE OF ARIZONA LICENSE