Provider Demographics
NPI:1669073748
Name:NORTHERN ARIZONA MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:NORTHERN ARIZONA MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZAFFAR
Authorized Official - Middle Name:
Authorized Official - Last Name:IQBAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-757-8440
Mailing Address - Street 1:3555 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3291
Mailing Address - Country:US
Mailing Address - Phone:928-757-8440
Mailing Address - Fax:928-757-8448
Practice Address - Street 1:3555 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3291
Practice Address - Country:US
Practice Address - Phone:928-757-8440
Practice Address - Fax:928-757-8448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ357676Medicaid