Healthcare Provider Details

I. General information

NPI: 1083401301
Provider Name (Legal Business Name): KEVIN SY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 04/21/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 W OLIVE AVE STE 102
GLENDALE AZ
85302-3147
US

IV. Provider business mailing address

5700 W OLIVE AVE STE 102
GLENDALE AZ
85302-3147
US

V. Phone/Fax

Practice location:
  • Phone: 623-387-3705
  • Fax: 623-439-7467
Mailing address:
  • Phone: 623-387-3705
  • Fax: 623-439-7467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number322427
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: