Provider Demographics
NPI:1992130884
Name:PECKHAM, JONATHAN DALE (PA-C)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DALE
Last Name:PECKHAM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41638
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85080-1638
Mailing Address - Country:US
Mailing Address - Phone:602-641-9486
Mailing Address - Fax:480-500-8430
Practice Address - Street 1:12361 W BOLA DR STE 100
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9021
Practice Address - Country:US
Practice Address - Phone:602-641-9486
Practice Address - Fax:480-500-8430
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5479363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ862609Medicaid
AZ862609Medicaid