Provider Demographics
NPI:1407820509
Name:HALL, JURGEN M (FNP)
Entity type:Individual
Prefix:
First Name:JURGEN
Middle Name:M
Last Name:HALL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8410 STARDUST TRL
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-3177
Mailing Address - Country:US
Mailing Address - Phone:928-527-0062
Mailing Address - Fax:
Practice Address - Street 1:8410 STARDUST TRAIL
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004
Practice Address - Country:US
Practice Address - Phone:928-737-6002
Practice Address - Fax:928-737-6001
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN091549163WG0000X
AZAP1515363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZMH1286663OtherDEA