Provider Demographics
NPI:1891727863
Name:AZ BD OF REGENTS FOR ON BEHALF OF NORTHERN AZ UNIVERSITY
Entity type:Organization
Organization Name:AZ BD OF REGENTS FOR ON BEHALF OF NORTHERN AZ UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD LCSW LCAS RN
Authorized Official - Phone:928-523-6343
Mailing Address - Street 1:PO BOX 6033
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86011-6033
Mailing Address - Country:US
Mailing Address - Phone:928-523-6343
Mailing Address - Fax:928-523-5730
Practice Address - Street 1:824 S SAN FRANCISCO ST
Practice Address - Street 2:BLDG 25 NORTHERN ARIZONA UNIVERSITY CAMPUS
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86011-0001
Practice Address - Country:US
Practice Address - Phone:928-523-6343
Practice Address - Fax:928-523-5730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3E115261QR0200X
261QS1000X
AZ03D0057902291U00000X
AZY0053363336C0003X
AZOTC5149261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No291U00000XLaboratoriesClinical Medical Laboratory
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy