Organization
LONE WOLF MEDICINE, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARILYN F HERON PAC (PHYSICIAN ASSISITANT)
(928) 474-6617
Entity
Organization
Contact information
Practice address
806 S PONDEROSA ST, PAYSON, AZ 85541-5541
(928) 474-6617
(928) 474-7059
Mailing address
PO BOX 1670, PAYSON, AZ 85547-1670
(928) 474-6617
(928) 474-7059
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
1454
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
137861
—
AZ
01
—
2Z0986
HEALTHNET
AZ
Enumeration date
08/21/2007
Last updated
08/21/2007
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