Healthcare Provider Details

I. General information

NPI: 1003211889
Provider Name (Legal Business Name): ERIC TOMAS OVALLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 N DYSART RD
AVONDALE AZ
85392-1208
US

IV. Provider business mailing address

3125 N DYSART RD
AVONDALE AZ
85392-1208
US

V. Phone/Fax

Practice location:
  • Phone: 602-726-8788
  • Fax: 480-420-0732
Mailing address:
  • Phone: 602-726-8788
  • Fax: 480-420-0732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5858
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: