Healthcare Provider Details

I. General information

NPI: 1700968377
Provider Name (Legal Business Name): THUNDERBIRD PODIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5620 W THUNDERBIRD G2
GLENDALE AZ
85306
US

IV. Provider business mailing address

5620 W THUNDERBIRD G2
GLENDALE AZ
85306
US

V. Phone/Fax

Practice location:
  • Phone: 602-938-3600
  • Fax: 602-938-0400
Mailing address:
  • Phone: 602-938-3600
  • Fax: 602-938-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateAZ

VIII. Authorized Official

Name: MRS. ANN HANSEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 602-938-3600