Healthcare Provider Details

I. General information

NPI: 1104503192
Provider Name (Legal Business Name): KYRA RENE WITBECK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
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 TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: