Healthcare Provider Details

I. General information

NPI: 1407167596
Provider Name (Legal Business Name): AHWATUKEE SKIN & LASER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 08/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 E AGAVE RD SUITE 148
PHOENIX AZ
85044-0619
US

IV. Provider business mailing address

4425 E AGAVE RD SUITE 148
PHOENIX AZ
85044-0619
US

V. Phone/Fax

Practice location:
  • Phone: 480-704-7546
  • Fax:
Mailing address:
  • Phone: 480-704-7546
  • Fax: 480-704-7549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number15963
License Number StateAZ

VIII. Authorized Official

Name: SARAH E NEUMANN
Title or Position: MANAGER, PROVIDER
Credential: PA-C
Phone: 480-704-7546