Provider Demographics
NPI:1780917369
Name:WOMEN CLINIC OF NORTHERN ARIZONA
Entity type:Organization
Organization Name:WOMEN CLINIC OF NORTHERN ARIZONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:O
Authorized Official - Last Name:SHIELS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-779-0341
Mailing Address - Street 1:1024 N SAN FRANCISCO ST STE 105
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3266
Mailing Address - Country:US
Mailing Address - Phone:928-779-0341
Mailing Address - Fax:928-774-4994
Practice Address - Street 1:1024 N SAN FRANCISCO ST STE 105
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3266
Practice Address - Country:US
Practice Address - Phone:928-779-0341
Practice Address - Fax:928-774-4994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22985207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty