Healthcare Provider Details

I. General information

NPI: 1942789367
Provider Name (Legal Business Name): JOEL PHILLIP MEDRANO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1665 N AVONDALE BLVD
AVONDALE AZ
85392-5006
US

IV. Provider business mailing address

20508 W DANIEL PL
BUCKEYE AZ
85396-3649
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-1000
  • Fax:
Mailing address:
  • Phone: 714-659-1969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP11637
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberTAP11637
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: