Healthcare Provider Details

I. General information

NPI: 1932733565
Provider Name (Legal Business Name): PHOENIX ANESTHESIA SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 PETROGLYPH POINT DR
PRESCOTT AZ
86301-6539
US

IV. Provider business mailing address

5242 W WHISPERING WIND DR
GLENDALE AZ
85310-2908
US

V. Phone/Fax

Practice location:
  • Phone: 325-660-5535
  • Fax:
Mailing address:
  • Phone: 325-660-5535
  • Fax: 325-692-6030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: POPPY WALKER
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 325-660-5535