Healthcare Provider Details

I. General information

NPI: 1386248078
Provider Name (Legal Business Name): VA MEDICAL CENTER IN PHOENIX AZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N US HIGHWAY 89
PRESCOTT AZ
86313-5001
US

IV. Provider business mailing address

PO BOX 12585
PRESCOTT AZ
86304-2585
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-4860
  • Fax:
Mailing address:
  • Phone: 602-619-2019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number
License Number State

VIII. Authorized Official

Name: TRAVIS MYERS
Title or Position: CHIEF OF RESPIRATORY CARE
Credential:
Phone: 928-445-4860