Healthcare Provider Details

I. General information

NPI: 1508801218
Provider Name (Legal Business Name): WENDY KAYE POURBASTANI ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6950 E WILLIAMS FIELD RD CARL T. HAYDEN VA MEDICAL CENTER, SOUTHEAST CLINIC
MESA AZ
85212-6033
US

IV. Provider business mailing address

1120 E HEARNE WAY
GILBERT AZ
85234-6018
US

V. Phone/Fax

Practice location:
  • Phone: 602-222-6568
  • Fax: 602-222-6496
Mailing address:
  • Phone: 480-497-9882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN068727
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: