Healthcare Provider Details

I. General information

NPI: 1619544145
Provider Name (Legal Business Name): SYED M SAQIB
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 W BASELINE RD
MESA AZ
85210-6041
US

IV. Provider business mailing address

612 W BASELINE RD
MESA AZ
85210-6041
US

V. Phone/Fax

Practice location:
  • Phone: 480-834-9039
  • Fax:
Mailing address:
  • Phone: 480-834-9039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number258027
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: