Healthcare Provider Details

I. General information

NPI: 1770171449
Provider Name (Legal Business Name): BRYCE BEATTY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 07/05/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W THOMAS RD
PHOENIX AZ
85013-4496
US

IV. Provider business mailing address

200 MULLINS DR
LEBANON OR
97355-3983
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-3000
  • Fax:
Mailing address:
  • Phone: 541-259-0235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number011349
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: