Healthcare Provider Details

I. General information

NPI: 1992353312
Provider Name (Legal Business Name): AZ PREMIER MOBILE PROVIDERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2737 E ARIZONA BILTMORE CIR UNIT 30
PHOENIX AZ
85016-2170
US

IV. Provider business mailing address

30 N GOULD ST STE R
SHERIDAN WY
82801-6317
US

V. Phone/Fax

Practice location:
  • Phone: 602-329-5743
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: COURTNEY HARRING
Title or Position: CREDENTIALING/ BILLING
Credential:
Phone: 678-761-5956