Healthcare Provider Details

I. General information

NPI: 1316504574
Provider Name (Legal Business Name): FOOT & ANKLE SPECIALISTS OF ARIZONA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18301 N 79TH AVE STE F168
GLENDALE AZ
85308-6045
US

IV. Provider business mailing address

18301 N 79TH AVE STE F168
GLENDALE AZ
85308-6045
US

V. Phone/Fax

Practice location:
  • Phone: 623-544-9090
  • Fax: 623-546-3704
Mailing address:
  • Phone: 623-544-9090
  • Fax: 623-546-3704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: SETH CLARK
Title or Position: OWNER
Credential: DPM
Phone: 623-544-9090