Provider Demographics
NPI:1588866453
Name:APACHE JUNCTION PEDIATRICS
Entity type:Organization
Organization Name:APACHE JUNCTION PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PEDIATRIC NURSE PRACTIONE
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:GRADLE
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:480-889-1234
Mailing Address - Street 1:1075 S IDAHO RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85219-6496
Mailing Address - Country:US
Mailing Address - Phone:480-889-1234
Mailing Address - Fax:
Practice Address - Street 1:1075 S IDAHO RD
Practice Address - Street 2:SUITE 206
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85219-6496
Practice Address - Country:US
Practice Address - Phone:480-889-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34596208000000X
AZ27900208000000X
AZ34587208000000X
AZAP0241208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0763370OtherJB BC ID
AZ088674Medicaid
AZ971409Medicaid
AZF14456Medicaid
AZ524729Medicaid
AZAZ0427690OtherRL BC ID
AZ907397Medicaid