Healthcare Provider Details

I. General information

NPI: 1477004935
Provider Name (Legal Business Name): PEDIATRIC ADULT ENDOCRINE GILBERT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 S VAL VISTA DR BLDG 10, SUITE 161
GILBERT AZ
85295
US

IV. Provider business mailing address

2730 S VAL VISTA DR BLDG 10, SUITE 161
GILBERT AZ
85295-1675
US

V. Phone/Fax

Practice location:
  • Phone: 480-821-2883
  • Fax: 480-237-5799
Mailing address:
  • Phone: 480-821-2883
  • Fax: 480-237-5799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. KHALID HASAN
Title or Position: OWNER
Credential: M.D.
Phone: 480-821-2883