Healthcare Provider Details

I. General information

NPI: 1174820542
Provider Name (Legal Business Name): NASRIN GHALYAIE M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2011
Last Update Date: 01/04/2022
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16601 N 40TH ST STE 204
PHOENIX AZ
85032-3356
US

IV. Provider business mailing address

2122 E HIGHLAND AVE STE 100
PHOENIX AZ
85016-4740
US

V. Phone/Fax

Practice location:
  • Phone: 602-996-4747
  • Fax: 602-953-5466
Mailing address:
  • Phone: 480-372-2111
  • Fax: 480-372-2112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number49656
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number49656
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: