Provider Demographics
NPI:1285780767
Name:CRYSTAL CANYON ENT & FACIAL PLASTIC SURGERY PC
Entity type:Organization
Organization Name:CRYSTAL CANYON ENT & FACIAL PLASTIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-774-1873
Mailing Address - Street 1:1340 N RIM DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3111
Mailing Address - Country:US
Mailing Address - Phone:928-774-1873
Mailing Address - Fax:928-774-5525
Practice Address - Street 1:1340 N RIM DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3111
Practice Address - Country:US
Practice Address - Phone:928-774-1873
Practice Address - Fax:928-774-5525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMD3000207K00000X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ316762Medicaid
AZ1000074OtherUNITED HEALTH CARE
AZAZ0228870OtherBCBSAZ
AZ316762Medicaid
AZZ29951Medicare ID - Type Unspecified