Healthcare Provider Details

I. General information

NPI: 1679608095
Provider Name (Legal Business Name): PHOENIX HEART, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 03/11/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5859 W TALAVI BLVD STE 100
GLENDALE AZ
85306-1870
US

IV. Provider business mailing address

5859 W TALAVI BLVD STE 100
GLENDALE AZ
85306-1870
US

V. Phone/Fax

Practice location:
  • Phone: 602-298-7777
  • Fax: 623-930-6060
Mailing address:
  • Phone: 602-298-7777
  • Fax: 623-930-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: LYSA MUNHALL
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 602-298-7777