Healthcare Provider Details

I. General information

NPI: 1093265183
Provider Name (Legal Business Name): TREVOR PATIENCE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2016
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1277 E MISSOURI AVE STE 102
PHOENIX AZ
85014-2916
US

IV. Provider business mailing address

1277 E MISSOURI AVE STE 102
PHOENIX AZ
85014-2916
US

V. Phone/Fax

Practice location:
  • Phone: 480-467-2273
  • Fax:
Mailing address:
  • Phone: 480-467-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6519
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: