Provider Demographics
NPI:1124055637
Name:ALTIC, JOHN M (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:ALTIC
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 1:888 S GREENFIELD RD #101
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4012
Mailing Address - Country:US
Mailing Address - Phone:480-892-1300
Mailing Address - Fax:480-504-7477
Practice Address - Street 1:888 S GREENFIELD RD #101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-4012
Practice Address - Country:US
Practice Address - Phone:480-892-1300
Practice Address - Fax:480-507-7477
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2502207P00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ726713Medicaid
AZZ141430Medicare PIN
AZZ141429Medicare PIN
AZ726713Medicaid
AZ71672Medicare ID - Type Unspecified