Basic Information
| Provider Information | |||||||||
| NPI: | 1457833923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLOUGH | ||||||||
| FirstName: | ROBIN | ||||||||
| MiddleName: | RECTOR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RECTOR | ||||||||
| OtherFirstName: | ROBIN | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331815 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1919 E THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850167710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029338510 | ||||||||
| FaxNumber: | 6029332697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2018 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 249616 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LP0222X | NP95009681 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics, Critical Care | 363LP0200X | 249616 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 082141 | 05 | AZ | MEDICAID |