Healthcare Provider Details

I. General information

NPI: 1699519389
Provider Name (Legal Business Name): ALY H SORO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21083 N JOHN WAYNE PKWY STE C104
MARICOPA AZ
85139-2961
US

IV. Provider business mailing address

3633 S DAWSON PL
TUCSON AZ
85730-3212
US

V. Phone/Fax

Practice location:
  • Phone: 520-233-7555
  • Fax:
Mailing address:
  • Phone: 520-833-6443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPTA-014644
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: