Provider Demographics
NPI:1073948550
Name:PAYNE, NATHAN BRADLEY (PA-C)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:BRADLEY
Last Name:PAYNE
Suffix:
Gender:M
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 1:1108 W INDIAN SCHOOL RD
Mailing Address - Street 2:STE B
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3107
Mailing Address - Country:US
Mailing Address - Phone:602-773-5600
Mailing Address - Fax:
Practice Address - Street 1:1108 W INDIAN SCHOOL RD
Practice Address - Street 2:STE B
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3107
Practice Address - Country:US
Practice Address - Phone:602-773-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2014-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5510363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ847251Medicaid
AZ847251Medicaid