Healthcare Provider Details

I. General information

NPI: 1851707293
Provider Name (Legal Business Name): MI DOCTORA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 E SOUTHERN AVE STE C101
MESA AZ
85204-5055
US

IV. Provider business mailing address

2545 W FRYE RD STE 5
CHANDLER AZ
85224-6273
US

V. Phone/Fax

Practice location:
  • Phone: 480-782-7380
  • Fax: 480-821-3610
Mailing address:
  • Phone: 480-821-3610
  • Fax: 480-821-3610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: HEATHER HARNER
Title or Position: CREDENTIALING
Credential:
Phone: 480-821-3610