Healthcare Provider Details

I. General information

NPI: 1972261196
Provider Name (Legal Business Name): ALEXANDER ETU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2021
Last Update Date: 12/05/2021
Certification Date: 12/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3207 S 73RD DR
PHOENIX AZ
85043-7230
US

IV. Provider business mailing address

401 W WESTERN AVE UNIT 345
AVONDALE AZ
85323-4414
US

V. Phone/Fax

Practice location:
  • Phone: 623-238-9777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN215721
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN215721
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN215721
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: