Healthcare Provider Details

I. General information

NPI: 1962699512
Provider Name (Legal Business Name): AHWATUKEE DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 E CHANDLER BLVD SUITE 305
PHOENIX AZ
85048-7643
US

IV. Provider business mailing address

4545 E CHANDLER BLVD SUITE 305
PHOENIX AZ
85048-7643
US

V. Phone/Fax

Practice location:
  • Phone: 480-785-7546
  • Fax: 480-940-1760
Mailing address:
  • Phone: 480-785-7546
  • Fax: 480-940-1760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number15963
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2590
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number151
License Number StateAZ

VIII. Authorized Official

Name: SARAH E NEUMANN
Title or Position: MANAGER
Credential: MMS, PA-C
Phone: 480-785-7546