Healthcare Provider Details

I. General information

NPI: 1194045740
Provider Name (Legal Business Name): MEGAN NICOLE WASSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2010
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 E MAYO BLVD
PHOENIX AZ
85054-4502
US

IV. Provider business mailing address

5777 E MAYO BLVD
PHOENIX AZ
85054-4502
US

V. Phone/Fax

Practice location:
  • Phone: 480-342-0612
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number006393
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number006393
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: