Healthcare Provider Details

I. General information

NPI: 1780349902
Provider Name (Legal Business Name): CANYON FAMILY MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6242 E ARBOR AVE STE 118
MESA AZ
85206-1309
US

IV. Provider business mailing address

6242 E ARBOR AVE STE 118
MESA AZ
85206-1309
US

V. Phone/Fax

Practice location:
  • Phone: 602-805-4914
  • Fax: 602-805-4917
Mailing address:
  • Phone: 602-805-4914
  • Fax: 602-805-4917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAURA AYN HAFEZ
Title or Position: FOUNDER
Credential: NP
Phone: 602-805-4914