Healthcare Provider Details

I. General information

NPI: 1780449348
Provider Name (Legal Business Name): CANYON PEDIATRICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 E UNIVERSITY DR
MESA AZ
85203-8032
US

IV. Provider business mailing address

2451 E BASELINE RD STE 130
GILBERT AZ
85234-2487
US

V. Phone/Fax

Practice location:
  • Phone: 480-776-7155
  • Fax:
Mailing address:
  • Phone: 480-776-7155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: RICHARD BRUBAKER
Title or Position: CEO
Credential: LMSW
Phone: 480-507-2199