Healthcare Provider Details

I. General information

NPI: 1952466500
Provider Name (Legal Business Name): BRIAN PAUL WARD PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E VAN BUREN ST
PHOENIX AZ
85006
US

IV. Provider business mailing address

PO BOX 86459
PHOENIX AZ
85080
US

V. Phone/Fax

Practice location:
  • Phone: 602-251-8316
  • Fax: 480-333-5165
Mailing address:
  • Phone: 602-251-8316
  • Fax: 480-333-5165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12265
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2891
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: