Healthcare Provider Details

I. General information

NPI: 1851841480
Provider Name (Legal Business Name): TAELYN DALLAS CARRIZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 N 19TH AVE STE 201
PHOENIX AZ
85021-7976
US

IV. Provider business mailing address

7550 N 19TH AVE STE 201
PHOENIX AZ
85021-7976
US

V. Phone/Fax

Practice location:
  • Phone: 480-963-1853
  • Fax:
Mailing address:
  • Phone: 480-963-1853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6513
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: