Healthcare Provider Details

I. General information

NPI: 1558236125
Provider Name (Legal Business Name): OWEN MCRAE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6644 E BAYWOOD AVE
MESA AZ
85206-1747
US

IV. Provider business mailing address

1550 N STAPLEY DR UNIT 1
MESA AZ
85203-3701
US

V. Phone/Fax

Practice location:
  • Phone: 480-321-2000
  • Fax:
Mailing address:
  • Phone: 480-980-6176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number330492
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN176023
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: