Healthcare Provider Details

I. General information

NPI: 1104763051
Provider Name (Legal Business Name): PK NEUROLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 N MESA DR STE 5
MESA AZ
85201-5936
US

IV. Provider business mailing address

5738 E STAR VALLEY ST
MESA AZ
85215-9664
US

V. Phone/Fax

Practice location:
  • Phone: 480-813-2906
  • Fax:
Mailing address:
  • Phone: 801-471-7340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PAUL LANIER
Title or Position: PRINCIPAL
Credential: DO
Phone: 801-471-7340