Healthcare Provider Details

I. General information

NPI: 1710141403
Provider Name (Legal Business Name): GLORY BUDHU RPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1533 E WILLETTA ST
PHOENIX AZ
85006-2935
US

IV. Provider business mailing address

1065 SOUTHERN BLVD
BRONX NY
10459-2417
US

V. Phone/Fax

Practice location:
  • Phone: 602-569-3999
  • Fax: 602-569-3887
Mailing address:
  • Phone: 718-589-2440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number012612
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5621
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: