Healthcare Provider Details

I. General information

NPI: 1346220860
Provider Name (Legal Business Name): TROY JOHN SELBY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4175 S ALAMO AVE
DM AFB AZ
85707-6097
US

IV. Provider business mailing address

4175 S ALAMO AVE
DM AFB AZ
85707-6097
US

V. Phone/Fax

Practice location:
  • Phone: 520-228-1593
  • Fax: 520-228-1522
Mailing address:
  • Phone: 520-228-1593
  • Fax: 520-228-1522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberNCCPA #1057937
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: