Healthcare Provider Details

I. General information

NPI: 1134636277
Provider Name (Legal Business Name): JON VINCENT SKORUPSKI CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 N CENTRAL AVE STE 1600
PHOENIX AZ
85004-4633
US

IV. Provider business mailing address

1850 N CENTRAL AVE STE 1600
PHOENIX AZ
85004-4633
US

V. Phone/Fax

Practice location:
  • Phone: 602-262-8900
  • Fax:
Mailing address:
  • Phone: 602-262-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN209136
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAZCRNA1471
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: