Healthcare Provider Details

I. General information

NPI: 1700618790
Provider Name (Legal Business Name): TRENTEN JAMES DIPPOLD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2024
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 12TH ST STE 500
PHOENIX AZ
85006-2849
US

IV. Provider business mailing address

555 N COLLEGE AVE APT 4047
TEMPE AZ
85288-0222
US

V. Phone/Fax

Practice location:
  • Phone: 602-839-4567
  • Fax:
Mailing address:
  • Phone: 814-706-5074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10657
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: