Healthcare Provider Details

I. General information

NPI: 1912187121
Provider Name (Legal Business Name): ARIZONA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 11/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7332 E. SUN DEVIL MALL
MESA AZ
85212
US

IV. Provider business mailing address

PO BOX 872104
TEMPE AZ
85287-2104
US

V. Phone/Fax

Practice location:
  • Phone: 480-727-1500
  • Fax: 480-727-1599
Mailing address:
  • Phone: 480-727-1500
  • Fax: 480-727-1599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateAZ

VIII. Authorized Official

Name: DR. ALLAN MARKUS
Title or Position: PHYSICIAN/DIRECTOR
Credential: M.D.
Phone: 480-965-1145