Basic Information
| Provider Information | |||||||||
| NPI: | 1710615620 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUANIMPTEWA | ||||||||
| FirstName: | THAYLIA | ||||||||
| MiddleName: | N/A | ||||||||
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| Mailing Information | |||||||||
| Address1: | HWY 264 MP388 | ||||||||
| Address2: | |||||||||
| City: | POLACCA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287376000 | ||||||||
| FaxNumber: | 9287376005 | ||||||||
| Practice Location | |||||||||
| Address1: | HWY 264 MP388 | ||||||||
| Address2: | |||||||||
| City: | POLACCA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287376000 | ||||||||
| FaxNumber: | 9287376005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2022 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247000000X | 1125148 | AZ | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Health Information |
ID Information
| ID | Type | State | Issuer | Description | 020529 | 05 | AZ | MEDICAID | 1125148 | 05 | AZ | MEDICAID |