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1510 E Wagon Wheel Ln Ste 104 Fort Mohave AZ 86426-6698 | |
| (928) 248-0518 | |
| (928) 514-2823 |
| Full Name | |
|---|---|
| Speciality | Internal Medicine |
| Location | 1510 E Wagon Wheel Ln Ste 104, Fort Mohave, Arizona |
| Authorized Official Name and Position | Wantzy Cooper (PRESIDENT) |
| Authorized Official Contact | 9282480518 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1510 E Wagon Wheel Ln Ste 104 Fort Mohave AZ 86426-6698 Ph: (928) 248-0518 | 1510 E Wagon Wheel Ln Ste 104 Fort Mohave AZ 86426-6698 Ph: (928) 248-0518 |
| NPI Number | 1669146536 |
|---|---|
| Provider Enumeration Date | 08/04/2021 |
| Last Update Date | 03/04/2024 |
| Medicare PECOS PAC ID | 2668863200 |
|---|---|
| Medicare Enrollment ID | O20240227004341 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1669146536 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (* (Not Available)) | Primary |
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Secondary |
| Provider Name | Guillermo G Zegarra |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1568478493 PECOS PAC ID: 1456391564 Enrollment ID: I20050509000540 |
| Provider Name | David M Freedman |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1356418305 PECOS PAC ID: 8820033889 Enrollment ID: I20080410000636 |
| Provider Name | Wantzy Cooper |
|---|---|
| Provider Type | Practitioner - Vascular Surgery |
| Provider Identifiers | NPI Number: 1942383393 PECOS PAC ID: 6002815214 Enrollment ID: I20110208000789 |
| Provider Name | John Adan |
|---|---|
| Provider Type | Practitioner - Cardiovascular Disease (cardiology) |
| Provider Identifiers | NPI Number: 1295709665 PECOS PAC ID: 5799747002 Enrollment ID: I20141114000312 |
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