Healthcare Provider Details

I. General information

NPI: 1275272353
Provider Name (Legal Business Name): TREY WATMORE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 E CAMBRIDGE AVE STE 201
PHOENIX AZ
85006-1462
US

IV. Provider business mailing address

5236 N 9TH ST
PHOENIX AZ
85014-2834
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-0500
  • Fax: 602-933-4320
Mailing address:
  • Phone: 602-350-0816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: