NPIMap

Individual provider Active NPI

Jeffrey Robert Flack, PA-C, ATC

  • Physician Assistant
  • Gilbert, AZ
National Provider Identifier
1275855231
Registry record updated Jun 3, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
5473 Issued in AZ
Practice address
890 W Elliot Rd
Suite 103
Gilbert, AZ 85233-5102
Phone
(480) 214-4466
NPI assigned
Feb 18, 2010
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 3, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Athletic Trainer 2255A2300X 0090 AZ
Physician Assistant 363A00000X 5473 AZ Primary

Addresses

Primary practice location

890 W Elliot Rd
Suite 103
Gilbert, AZ 85233-5102

Mailing address

890 W Elliot Rd
Suite 103
Gilbert, AZ 85233-5102
Phone (480) 214-4466

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20131010000501 AZ Practitioner - Physician Assistant 6002040896 Reassigns benefits to 4 organizations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
0090AZMDAthletic Trainer

Practice roles

OrganizationSpecialtyStatusNew patients
Tri-City Express Care, PLLC Past Accepting new patients
Tri-City Express Care, PLLC Past Accepting new patients
Tri-City Express Care, PLLC Past Accepting new patients
Tri-City Express Care, PLLC Past Accepting new patients
Tri-City Express Care, PLLC Past Accepting new patients

Organizations & group practices 9

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1266451200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1401753600000",
    "number": "1275855231",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "890 W ELLIOT RD",
            "address_2": "SUITE 103",
            "city": "GILBERT",
            "state": "AZ",
            "postal_code": "852335102",
            "telephone_number": "480-214-4466"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "890 W ELLIOT RD",
            "address_2": "SUITE 103",
            "city": "GILBERT",
            "state": "AZ",
            "postal_code": "852335102",
            "telephone_number": "480-214-4466"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FLACK",
        "first_name": "JEFFREY",
        "middle_name": "ROBERT",
        "credential": "PA-C, ATC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2010-02-18",
        "last_updated": "2014-06-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "AZ",
            "license": "0090",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "AZ",
            "license": "5473",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Gilbert, AZ

Sources for this page

Verify at the official NPI Registry.