Provider Demographics
NPI:1972990851
Name:PACKARD, JOEL (CSFA)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:PACKARD
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 PINE DEL DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86005-9603
Mailing Address - Country:US
Mailing Address - Phone:928-699-6786
Mailing Address - Fax:
Practice Address - Street 1:50 PINE DEL DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86005-9603
Practice Address - Country:US
Practice Address - Phone:928-699-6786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-18
Last Update Date:2015-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant