Healthcare Provider Details

I. General information

NPI: 1083024921
Provider Name (Legal Business Name): MITCHELL RYAN MANWAY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 02/20/2024
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20401 N 73RD ST STE 230
SCOTTSDALE AZ
85255-4153
US

IV. Provider business mailing address

20401 N 73RD ST SUITE 230
SCOTTSDALE AZ
85255-4107
US

V. Phone/Fax

Practice location:
  • Phone: 480-556-0446
  • Fax: 480-556-0447
Mailing address:
  • Phone: 480-556-0446
  • Fax: 480-556-0447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number7027
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number7027
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number007027
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS13524
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: