Healthcare Provider Details

I. General information

NPI: 1801162854
Provider Name (Legal Business Name): VALLEY OF THE SUN PEDIATRICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2012
Last Update Date: 03/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 W HAPPY VALLEY RD STE 125
PEORIA AZ
85383-2878
US

IV. Provider business mailing address

10200 W HAPPY VALLEY RD STE 125
PEORIA AZ
85383-2878
US

V. Phone/Fax

Practice location:
  • Phone: 623-362-1818
  • Fax: 623-362-8095
Mailing address:
  • Phone: 623-362-1818
  • Fax: 623-362-8095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number33560
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP3855
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP4013
License Number StateAZ

VIII. Authorized Official

Name: ED MATROSE
Title or Position: OFFICE MANAGER
Credential:
Phone: 623-362-1818