Healthcare Provider Details

I. General information

NPI: 1619055662
Provider Name (Legal Business Name): LAVERN K SCHEPP P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1424 S 7TH AVE BLDG C
PHOENIX AZ
85007-3902
US

IV. Provider business mailing address

3450 N 3RD ST
PHOENIX AZ
85012-2331
US

V. Phone/Fax

Practice location:
  • Phone: 602-258-3600
  • Fax: 602-256-0514
Mailing address:
  • Phone: 602-265-8338
  • Fax: 602-265-8574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1287
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: