Basic Information
| Provider Information | |||||||||
| NPI: | 1740681212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEDONI | ||||||||
| FirstName: | FREDRICK | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207 | ||||||||
| Address2: | |||||||||
| City: | POLACCA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860420207 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | HIGHWAY 264 MILEPOST 388 | ||||||||
| Address2: | |||||||||
| City: | POLACCA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860420207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287376000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2014 | ||||||||
| LastUpdateDate: | 09/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN162871 | AZ | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 020529 | 05 | AZ | MEDICAID |