Healthcare Provider Details

I. General information

NPI: 1871401307
Provider Name (Legal Business Name): JUAN SALVADOR CANONERO ALTURA FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3219 E JEROME AVE
MESA AZ
85204-7317
US

IV. Provider business mailing address

3219 E JEROME AVE
MESA AZ
85204-7317
US

V. Phone/Fax

Practice location:
  • Phone: 732-599-4109
  • Fax:
Mailing address:
  • Phone: 732-599-4109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN217095
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: