Healthcare Provider Details

I. General information

NPI: 1992670301
Provider Name (Legal Business Name): DOUGLAS WILLIAM RAE MSN, APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2025
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N CENTRAL AVE STE 200
PHOENIX AZ
85004-1844
US

IV. Provider business mailing address

1101 N CENTRAL AVE STE 200
PHOENIX AZ
85004-1844
US

V. Phone/Fax

Practice location:
  • Phone: 602-307-5330
  • Fax: 602-307-5021
Mailing address:
  • Phone: 602-307-5330
  • Fax: 602-307-5021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number269501
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: