Healthcare Provider Details

I. General information

NPI: 1669707709
Provider Name (Legal Business Name): SIERRA WOLTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016
US

IV. Provider business mailing address

3200 E CAMELBACK RD STE 250
PHOENIX AZ
85018-2327
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-0895
  • Fax: 602-933-2436
Mailing address:
  • Phone: 602-933-1813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberNONE
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number49602
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: