Healthcare Provider Details

I. General information

NPI: 1477496925
Provider Name (Legal Business Name): AZ ADVANCED WOUND CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4838 E BASELINE RD. BLDG 2 STE 113
MESA AZ
85206-4674
US

IV. Provider business mailing address

4838 E BASELINE RD STE 113
MESA AZ
85206-4674
US

V. Phone/Fax

Practice location:
  • Phone: 602-835-3809
  • Fax: 480-944-0859
Mailing address:
  • Phone: 602-835-3809
  • Fax: 480-944-0859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: BREANNA N WALLER
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 615-723-2828