Healthcare Provider Details

I. General information

NPI: 1780255695
Provider Name (Legal Business Name): VANORA ANN DSA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2021
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 N COUNTRY CLUB DR STE 1
MESA AZ
85201-5700
US

IV. Provider business mailing address

606 N COUNTRY CLUB DR STE 1
MESA AZ
85201-5700
US

V. Phone/Fax

Practice location:
  • Phone: 809-631-8534
  • Fax: 480-963-1854
Mailing address:
  • Phone: 480-963-1853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number74430
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: