Healthcare Provider Details

I. General information

NPI: 1104263292
Provider Name (Legal Business Name): NICOLE ANNE KONKOWSKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2013
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W BETHANY HOME RD
PHOENIX AZ
85015-2443
US

IV. Provider business mailing address

2000 W BETHANY HOME RD
PHOENIX AZ
85015-2443
US

V. Phone/Fax

Practice location:
  • Phone: 602-246-5525
  • Fax:
Mailing address:
  • Phone: 602-246-5525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR74051
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: