Healthcare Provider Details

I. General information

NPI: 1396468443
Provider Name (Legal Business Name): JUAN CARLOS PALLARES-SALAZAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3016 E MONTE VISTA RD
PHOENIX AZ
85008-2834
US

IV. Provider business mailing address

3016 E MONTE VISTA RD
PHOENIX AZ
85008-2834
US

V. Phone/Fax

Practice location:
  • Phone: 602-518-0773
  • Fax:
Mailing address:
  • Phone: 602-518-0773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number232109
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: