Healthcare Provider Details

I. General information

NPI: 1124751227
Provider Name (Legal Business Name): YAVAPAI UROLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 ROTONDA WAY
PRESCOTT AZ
86301-4493
US

IV. Provider business mailing address

1042 WILLOW CREEK RD STE A101-138
PRESCOTT AZ
86301-1673
US

V. Phone/Fax

Practice location:
  • Phone: 661-208-1182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: SYMPHONY WITTENBERG
Title or Position: PRACTICE MANAGER
Credential:
Phone: 661-208-1182