Provider Demographics
NPI:1871582635
Name:PORVAZNIK, MARY CATHERINE (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:CATHERINE
Last Name:PORVAZNIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1501 S YALE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7304
Mailing Address - Country:US
Mailing Address - Phone:928-527-4325
Mailing Address - Fax:928-527-4327
Practice Address - Street 1:1501 S YALE ST STE 2
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7304
Practice Address - Country:US
Practice Address - Phone:928-527-4325
Practice Address - Fax:928-527-4327
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2023-09-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ22035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50553771Medicaid
NMZ3755Medicaid
AZ434853Medicaid
NMZ3755Medicaid
H44414Medicare UPIN