Healthcare Provider Details

I. General information

NPI: 1851863476
Provider Name (Legal Business Name): HIMANSHU RAJ ULLAL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2018
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5882 S HOSPITAL DR STE 1
GLOBE AZ
85501-9455
US

IV. Provider business mailing address

1630 E ASH ST
GLOBE AZ
85501-1430
US

V. Phone/Fax

Practice location:
  • Phone: 928-793-3747
  • Fax: 928-793-3745
Mailing address:
  • Phone: 928-812-3198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: