Basic Information
| Provider Information | |||||||||
| NPI: | 1962474361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JICHA | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6653 MAIN STREET | ||||||||
| Address2: | THE EXIGENCE GROUP C O JANENE FARLEY | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168172932 | ||||||||
| FaxNumber: | 7162044501 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 E FLORENCE BLVD | ||||||||
| Address2: | |||||||||
| City: | CASA GRANDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852225303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203816300 | ||||||||
| FaxNumber: | 5203816618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 08/20/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2388 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 548745 | 05 | AZ | MEDICAID |