Basic Information
| Provider Information | |||||||||
| NPI: | 1770638827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEASY | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCOTT | ||||||||
| OtherFirstName: | KATHY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 600 | ||||||||
| Address2: | 167 NORTH MAIN STREET | ||||||||
| City: | TUBA CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860450600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282832501 | ||||||||
| FaxNumber: | 9282832677 | ||||||||
| Practice Location | |||||||||
| Address1: | 167 NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | TUBA CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860450600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282832501 | ||||||||
| FaxNumber: | 9282832677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 26566 | AZ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 01026217 | IN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 453126 | 05 | AZ | MEDICAID |