Provider Demographics
NPI:1770543506
Name:EAGLE, GLORIA JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:JEAN
Last Name:EAGLE
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 1:400 S CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-4467
Mailing Address - Country:US
Mailing Address - Phone:928-669-6151
Mailing Address - Fax:928-669-8403
Practice Address - Street 1:1200 W MOHAVE RD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-6349
Practice Address - Country:US
Practice Address - Phone:928-669-7380
Practice Address - Fax:928-669-7371
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1932363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ158539Medicaid
AZA20324620OtherBLUE CROSS BLUE SHEILD
AZP00279265OtherRAIL ROAD MEDICARE
AZS98946Medicare UPIN
AZ158539Medicaid