Healthcare Provider Details

I. General information

NPI: 1205689171
Provider Name (Legal Business Name): CORNER HEALTH MEDICAL GROUP P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2024
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 N CENTRAL AVE
PHOENIX AZ
85004-2322
US

IV. Provider business mailing address

PO BOX 96770
PHOENIX AZ
85072-6770
US

V. Phone/Fax

Practice location:
  • Phone: 602-123-4567
  • Fax:
Mailing address:
  • Phone: 425-243-3719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LAVANYA SUNDER
Title or Position: CEO
Credential:
Phone: 404-860-3441