Healthcare Provider Details

I. General information

NPI: 1609078997
Provider Name (Legal Business Name): PHOENIX SKIN II PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5056 N CENTRAL AVE
PHOENIX AZ
85012-1521
US

IV. Provider business mailing address

5056 N CENTRAL AVE
PHOENIX AZ
85012-1521
US

V. Phone/Fax

Practice location:
  • Phone: 602-222-9111
  • Fax: 602-277-5111
Mailing address:
  • Phone: 602-222-9111
  • Fax: 602-277-5111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LEE P LARIS
Title or Position: PHYSICIAN
Credential: DO
Phone: 602-222-9111