Provider Demographics
NPI:1295725067
Name:KINNEY, ARCHIE M (PA C)
Entity type:Individual
Prefix:
First Name:ARCHIE
Middle Name:M
Last Name:KINNEY
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:WHITERIVER INDIAN HOSPITAL
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:928-338-1122
Practice Address - Street 1:200 WEST HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941-0860
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:928-338-1122
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1148363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ698821Medicaid
AZ1427335140Medicaid
AZ1427335181Medicaid
AZ970030184OtherRAILROAD
AZ1427335181Medicaid
HSZ240Medicare PIN
AZ970030184OtherRAILROAD
030113Medicare Oscar/Certification