Provider Demographics
NPI:1548643836
Name:AZ AT HOME INC
Entity type:Organization
Organization Name:AZ AT HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:480-275-2022
Mailing Address - Street 1:12630 N 103RD AVE STE 142
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3463
Mailing Address - Country:US
Mailing Address - Phone:480-275-2022
Mailing Address - Fax:888-551-6092
Practice Address - Street 1:12630 N 103RD AVE STE 142
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3463
Practice Address - Country:US
Practice Address - Phone:480-275-2022
Practice Address - Fax:888-551-6092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-04
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN078764363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ031189Medicaid
AZ769044Medicaid
AZ031189Medicaid