Healthcare Provider Details

I. General information

NPI: 1780270926
Provider Name (Legal Business Name): BRYAN JUSTIN DWIGGINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 E MISSOURI AVE STE 300
PHOENIX AZ
85012-1351
US

IV. Provider business mailing address

645 E MISSOURI AVE STE 300
PHOENIX AZ
85012-1351
US

V. Phone/Fax

Practice location:
  • Phone: 602-262-8900
  • Fax: 602-262-8890
Mailing address:
  • Phone: 602-262-8917
  • Fax: 602-262-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9496691
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number254265
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: