Basic Information
| Provider Information | |||||||||
| NPI: | 1588122923 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUSTAD | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13460 N 94TH DR STE J1 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238768816 | ||||||||
| FaxNumber: | 6232980168 | ||||||||
| Practice Location | |||||||||
| Address1: | 13460 N 94TH DR STE J1 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238768816 | ||||||||
| FaxNumber: | 6232980168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2019 | ||||||||
| LastUpdateDate: | 11/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 7365 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 504592 | 05 | AZ | MEDICAID | 7365 | 01 | AZ | ARIZONA BOARD OF PHYSICIAN ASSISTANTS | OTHER |