Healthcare Provider Details

I. General information

NPI: 1952927048
Provider Name (Legal Business Name): JOHN LEO CONWAY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 E CLAREMONT ST
PHOENIX AZ
85016-1514
US

IV. Provider business mailing address

1705 E CLAREMONT ST
PHOENIX AZ
85016-1514
US

V. Phone/Fax

Practice location:
  • Phone: 602-989-4806
  • Fax:
Mailing address:
  • Phone: 602-989-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRNP-240978
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: