Healthcare Provider Details

I. General information

NPI: 1962089730
Provider Name (Legal Business Name): AUSTIN KIMBALL TRAASDAHL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3048 E BASELINE RD STE 120
MESA AZ
85204-7288
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 480-505-3276
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number2024017742
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: