Healthcare Provider Details

I. General information

NPI: 1679556641
Provider Name (Legal Business Name): LAURA E KLUSOVSKY P.A.-C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777E MAYO BLVD
PHOENIX AZ
85054-4502
US

IV. Provider business mailing address

5777E MAYO BLVD
PHOENIX AZ
85054-4502
US

V. Phone/Fax

Practice location:
  • Phone: 480-342-2928
  • Fax:
Mailing address:
  • Phone: 480-342-2928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number3331
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3331
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3331
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3331
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: