MEDICARE: ARIZONA PREMIER DERMATOLOGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	RN066390	AZ

General Provider Information

NPI Number	:	1538473939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARIZONA PREMIER DERMATOLOGY, LLC

Provider Business Mailing Address
First Line	:	4545 E CHANDLER BLVD STE 305
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-7646
Country	:	US
Telephone Number	:	480-753-3376
Fax Number	:	480-545-2673

Provider Business Practice Location Address
First Line	:	4545 E CHANDLER BLVD STE 305
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-7646
Country	:	US
Telephone Number	:	480-753-3376
Fax Number	:	480-545-2673

Authorized Official
Title or Position	:	MANAGER
Name	:	ELIZABETH MEYER
Credential	:
Telephone Number	:	480-545-2610

Provider Enumeration Date	:	07/28/2010
Last Update Date	:	07/28/2010

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