Healthcare Provider Details

I. General information

NPI: 1265297097
Provider Name (Legal Business Name): SHAUN CHRISTIAN JAVA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date: 04/26/2024
Reactivation Date: 05/28/2024

III. Provider practice location address

19829 N 27TH AVE
PHOENIX AZ
85027-4001
US

IV. Provider business mailing address

12124 W COTTONTAIL LN
PEORIA AZ
85383-5829
US

V. Phone/Fax

Practice location:
  • Phone: 623-879-6100
  • Fax:
Mailing address:
  • Phone: 602-299-4548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number306567
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN174293
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: