Healthcare Provider Details

I. General information

NPI: 1619507233
Provider Name (Legal Business Name): DANIELLA ROSEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DANIELLA POURMORADI

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6678 W THUNDERBIRD RD
GLENDALE AZ
85306-3721
US

IV. Provider business mailing address

6678 W THUNDERBIRD RD
GLENDALE AZ
85306-3721
US

V. Phone/Fax

Practice location:
  • Phone: 602-978-1500
  • Fax: 602-978-0409
Mailing address:
  • Phone: 602-978-1500
  • Fax: 602-978-0409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9150
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: