Provider Demographics
NPI:1962558569
Name:NORTHERN ARIZONA DERMATOLOGY CENTER PC
Entity type:Organization
Organization Name:NORTHERN ARIZONA DERMATOLOGY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:ACKERMAN
Authorized Official - Last Name:KNUTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-774-5074
Mailing Address - Street 1:1490 N TURQUOISE DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-774-5074
Mailing Address - Fax:928-779-0884
Practice Address - Street 1:1490 N TURQUOISE DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-774-5074
Practice Address - Fax:928-779-0884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICA010529OtherLIABILITY INSURANCE
MICA03976OtherLIABILITY INSURANCE
295114OtherAHCCCS
MICA03876OtherLIABILITY INSURANCE
19361OtherAZ LICENSE
MICA03874OtherLIABILITY INSURANCE
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33121OtherAZ LICENSE
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30215OtherAZ LICENSE
MICA014013OtherLIABILITY INSURANCE
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AK7549681OtherDEA
BC5837894OtherDEA
25924OtherAZ LICENSE
30215OtherAZ LICENSE
MICA014013OtherLIABILITY INSURANCE
BH1999905OtherDEA