Healthcare Provider Details

I. General information

NPI: 1346461803
Provider Name (Legal Business Name): DEBRA GREGORY BAYHAM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 11/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E VIRGINIA AVE 220
PHOENIX AZ
85004-1206
US

IV. Provider business mailing address

333 E VIRGINIA AVE 220
PHOENIX AZ
85004-1206
US

V. Phone/Fax

Practice location:
  • Phone: 602-258-9955
  • Fax: 602-258-9933
Mailing address:
  • Phone: 602-258-9955
  • Fax: 602-258-9933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2270
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: