Provider Demographics
NPI:1174698617
Name:MCPHEETERS, LORETTA KATHERINE (PA-C)
Entity type:Individual
Prefix:MS
First Name:LORETTA
Middle Name:KATHERINE
Last Name:MCPHEETERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 N CENTRAL AVE BLDG C
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3313
Mailing Address - Country:US
Mailing Address - Phone:602-279-5262
Mailing Address - Fax:602-279-5390
Practice Address - Street 1:4041 N CENTRAL AVE BLDG C
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3313
Practice Address - Country:US
Practice Address - Phone:602-279-5262
Practice Address - Fax:602-279-5390
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2959363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ946056Medicaid