Healthcare Provider Details

I. General information

NPI: 1639567142
Provider Name (Legal Business Name): PAUL DARRELL CAGLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 E MARLETTE AVE APT 28S
PHOENIX AZ
85014-1512
US

IV. Provider business mailing address

940 E MARLETTE AVE APT 28S
PHOENIX AZ
85014
US

V. Phone/Fax

Practice location:
  • Phone: 480-430-9843
  • Fax:
Mailing address:
  • Phone: 480-430-9843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4970
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: