Healthcare Provider Details

I. General information

NPI: 1710545355
Provider Name (Legal Business Name): IDRIS A IDRIS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 W UNION HILLS DR STE 111
GLENDALE AZ
85308-2430
US

IV. Provider business mailing address

3515 W UNION HILLS DR STE 111
GLENDALE AZ
85308-2430
US

V. Phone/Fax

Practice location:
  • Phone: 623-328-8630
  • Fax: 623-243-7842
Mailing address:
  • Phone: 623-328-8630
  • Fax: 623-243-7842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF01190538
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: