Provider Demographics
NPI:1740262724
Name:DURSTELER, JENNIFER GRAHAM (PA C)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:GRAHAM
Last Name:DURSTELER
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 1:12810 S 177TH AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-5796
Mailing Address - Country:US
Mailing Address - Phone:480-570-5848
Mailing Address - Fax:
Practice Address - Street 1:13677 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-2618
Practice Address - Country:US
Practice Address - Phone:623-882-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2709207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAW1436OtherHEALTHNET GROUP #
AZ453051001OtherGROUP HEALTH GROUP #
AZ762155Medicaid
AZ860373636OtherHUMANA GROUP #
AZ3981220OtherEVERCARE GROUP #
AZ103632Medicare PIN
AZ860373636OtherHUMANA GROUP #