Provider Demographics
NPI:1396784930
Name:NALLY, ADAM SHANE (DO)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:SHANE
Last Name:NALLY
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Gender:M
Credentials:DO
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Mailing Address - Street 1:14800 W MOUNTAIN VIEW BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-4795
Mailing Address - Country:US
Mailing Address - Phone:623-584-7805
Mailing Address - Fax:623-584-7856
Practice Address - Street 1:14800 W MOUNTAIN VIEW BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-4795
Practice Address - Country:US
Practice Address - Phone:623-584-7805
Practice Address - Fax:623-584-7856
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-08-14
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Provider Licenses
StateLicense IDTaxonomies
AZ3587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ704199Medicaid
AZ1811186802OtherCORPRATE NPI
AZ68796Medicare PIN
AZ704199Medicaid