Healthcare Provider Details

I. General information

NPI: 1437424983
Provider Name (Legal Business Name): PABLO C ACOSTA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2012
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16113 W CORONADO RD
GOODYEAR AZ
85395-7130
US

IV. Provider business mailing address

161 E RIVULON BLVD STE 210
GILBERT AZ
85297-0087
US

V. Phone/Fax

Practice location:
  • Phone: 623-695-0449
  • Fax:
Mailing address:
  • Phone: 480-494-2465
  • Fax: 480-534-4087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP7817
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN110209
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: