Healthcare Provider Details

I. General information

NPI: 1750571923
Provider Name (Legal Business Name): STACI BRYSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S DOBSON RD
MESA AZ
85202-4707
US

IV. Provider business mailing address

PO BOX 42210
PHOENIX AZ
85080-2210
US

V. Phone/Fax

Practice location:
  • Phone: 602-685-5211
  • Fax: 602-685-5325
Mailing address:
  • Phone: 623-266-7770
  • Fax: 623-322-4639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number51046
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number51046
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: