| Organization Name: | LONE WOLF MEDICINE, INC |
| NPI Number: | 1053504225 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MARILYN F HERON (PHYSICIAN ASSISITANT) |
| Mailing Address: | 806 S Ponderosa St Payson |
| State: | AZ US |
| Postal Code: | 855415541 |
| Phone Number: | 9284746617 |
| Fax Number: | 9284747059 |
| NPI Enumeration Date: | 08/21/2007 |
| NPI Last Update Date: | 08/21/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | 1454 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AZ |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |