Provider Demographics
NPI:1528054855
Name:CEBALLOS, PATRICIA I (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:I
Last Name:CEBALLOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PATRICIA
Other - Middle Name:I
Other - Last Name:CEBALLOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:830 AINSWORTH DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1630
Practice Address - Country:US
Practice Address - Phone:928-777-5800
Practice Address - Fax:928-776-0405
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ62481207NS0135X, 207ZD0900X, 207ND0101X, 207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF63048Medicare UPIN
FL10541YMedicare PIN