Basic Information
| Provider Information | |||||||||
| NPI: | 1740494186 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TANQUE VERDE PEDIATRICS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7265 E TANQUE VERDE RD | ||||||||
| Address2: | SUITE 121 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857153466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207222585 | ||||||||
| FaxNumber: | 5207221097 | ||||||||
| Practice Location | |||||||||
| Address1: | 7265 E TANQUE VERDE RD | ||||||||
| Address2: | SUITE 121 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857153466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207222585 | ||||||||
| FaxNumber: | 5207221097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | RICKEY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5207222585 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | AZ14264 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.