Basic Information
Provider Information | |||||||||
NPI: | 1134577810 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHRISTENSEN | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | CLAYTON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12361 W BOLA DR STE 109 | ||||||||
Address2: |   | ||||||||
City: | SURPRISE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853789021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6232271000 | ||||||||
FaxNumber: | 6232272000 | ||||||||
Practice Location | |||||||||
Address1: | 2286 CROSSWIND DR STE C | ||||||||
Address2: |   | ||||||||
City: | PRESCOTT | ||||||||
State: | AZ | ||||||||
PostalCode: | 863016100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282084598 | ||||||||
FaxNumber: | 6232272000 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2016 | ||||||||
LastUpdateDate: | 04/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD193733 | OR | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207R00000X | 64482 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 107409 | 05 | AZ |   | MEDICAID | Q00214136 | 01 | AZ | RAILROAD MEDICARE | OTHER |