Healthcare Provider Details

I. General information

NPI: 1265798664
Provider Name (Legal Business Name): ARIZONA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N 3RD ST
PHOENIX AZ
85004-2135
US

IV. Provider business mailing address

500 N 3RD ST
PHOENIX AZ
85004-2135
US

V. Phone/Fax

Practice location:
  • Phone: 602-496-0721
  • Fax:
Mailing address:
  • Phone: 602-496-0721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberAP4432
License Number StateAZ

VIII. Authorized Official

Name: MR. SAMUEL YOUNGER
Title or Position: MANAGER NP HEALTHCARE
Credential: MHA FACHE
Phone: 602-496-0721