Healthcare Provider Details

I. General information

NPI: 1235620170
Provider Name (Legal Business Name): STEPHANIE DEBORAH KOTSUR NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2018
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21321 E OCOTILLO RD STE 133
QUEEN CREEK AZ
85142-5995
US

IV. Provider business mailing address

21321 E OCOTILLO RD STE 133
QUEEN CREEK AZ
85142-5995
US

V. Phone/Fax

Practice location:
  • Phone: 480-987-5525
  • Fax: 480-987-5115
Mailing address:
  • Phone: 480-987-5525
  • Fax: 480-987-5115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAP11222
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP11222
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: