| Gold Canyon Internal Medicine, Pllc | |
|
6724 S Kings Ranch Rd Ste 102 Gold Canyon AZ 85118-2963 | |
| (480) 626-4999 | |
| (480) 304-3239 |
| Full Name | Gold Canyon Internal Medicine, Pllc |
|---|---|
| Speciality | Internal Medicine |
| Location | 6724 S Kings Ranch Rd Ste 102, Gold Canyon, Arizona |
| Authorized Official Name and Position | Jerrelle M Copeland (OWNER) |
| Authorized Official Contact | 4803702602 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Gold Canyon Internal Medicine, Pllc 6724 S Kings Ranch Rd Ste 102 Gold Canyon AZ 85118-2963 Ph: (480) 626-4999 | Gold Canyon Internal Medicine, Pllc 6724 S Kings Ranch Rd Ste 102 Gold Canyon AZ 85118-2963 Ph: (480) 626-4999 |
| NPI Number | 1417112541 |
|---|---|
| Provider Enumeration Date | 07/29/2008 |
| Last Update Date | 09/30/2024 |
| Medicare PECOS PAC ID | 0840552675 |
|---|---|
| Medicare Enrollment ID | O20180314002521 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1417112541 | NPI | - | NPPES |
| 404723 | Medicaid | AZ |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | 25933 (Arizona) | Primary |
| Provider Name | Jerrelle M Copeland |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1790784643 PECOS PAC ID: 5193746444 Enrollment ID: I20051214000283 |
| Provider Name | Romella Icban Watler |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1619454154 PECOS PAC ID: 3577997261 Enrollment ID: I20200106002522 |
| Provider Name | Amy Sue Simmons |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1366953143 PECOS PAC ID: 4183055445 Enrollment ID: I20200520003778 |
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