Healthcare Provider Details

I. General information

NPI: 1912152026
Provider Name (Legal Business Name): BRIAN MCINTOSH PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5251 W CAMPBELL AVE SUITE 105
PHOENIX AZ
85031-1715
US

IV. Provider business mailing address

9221 E BASELINE RD SUITE A109-617
MESA AZ
85209-8310
US

V. Phone/Fax

Practice location:
  • Phone: 623-245-0505
  • Fax: 480-357-4639
Mailing address:
  • Phone: 480-357-3904
  • Fax: 480-357-4639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4331
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: