Healthcare Provider Details

I. General information

NPI: 1588111264
Provider Name (Legal Business Name): BRIAN THOMAS PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 N 3RD ST
PHOENIX AZ
85004-1106
US

IV. Provider business mailing address

202 E EARLL DR #200
PHOENIX AZ
85012-2634
US

V. Phone/Fax

Practice location:
  • Phone: 602-808-2800
  • Fax: 602-808-2799
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP8948
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: