Provider Demographics
NPI:1538354188
Name:COPPER BASIN FAMILY MEDICINE PLLC
Entity type:Organization
Organization Name:COPPER BASIN FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:HOOSE
Authorized Official - Suffix:
Authorized Official - Credentials:RN MSN FNP-C
Authorized Official - Phone:480-888-2010
Mailing Address - Street 1:20185 E OCOTILLO RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85242-7663
Mailing Address - Country:US
Mailing Address - Phone:480-888-2010
Mailing Address - Fax:480-888-2074
Practice Address - Street 1:20185 E OCOTILLO RD
Practice Address - Street 2:SUITE 104
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85242-7663
Practice Address - Country:US
Practice Address - Phone:480-888-2010
Practice Address - Fax:480-888-2074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2470363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ237244Medicaid
AZZ120087Medicare UPIN