Healthcare Provider Details

I. General information

NPI: 1093415408
Provider Name (Legal Business Name): PHOENIX VASCULAR ACCESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 N MESA DR STE 16
MESA AZ
85201-5936
US

IV. Provider business mailing address

455 N MESA DR STE 16
MESA AZ
85201-5936
US

V. Phone/Fax

Practice location:
  • Phone: 480-468-3219
  • Fax:
Mailing address:
  • Phone: 480-468-3219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOSIE BRANDON JOHN HART
Title or Position: CEO
Credential:
Phone: 480-468-3219