Healthcare Provider Details

I. General information

NPI: 1972563187
Provider Name (Legal Business Name): FAMILY PRACTICE SPECIALISTS LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 E SHEA BLVD STE 100
PHOENIX AZ
85028-6031
US

IV. Provider business mailing address

4600 E SHEA BLVD STE 100
PHOENIX AZ
85028-6031
US

V. Phone/Fax

Practice location:
  • Phone: 602-955-8700
  • Fax: 602-553-8142
Mailing address:
  • Phone: 602-955-8700
  • Fax: 602-553-8142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateAZ

VIII. Authorized Official

Name: DR. MARK A WYSE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 602-955-8700