Healthcare Provider Details

I. General information

NPI: 1275597221
Provider Name (Legal Business Name): EAST VALLEY PEDIATRIC PULMONARY SPECIALISTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10250 N 92ND ST 308
SCOTTSDALE AZ
85258-4510
US

IV. Provider business mailing address

10250 N 92ND ST 308
SCOTTSDALE AZ
85258-4510
US

V. Phone/Fax

Practice location:
  • Phone: 480-614-6655
  • Fax:
Mailing address:
  • Phone: 480-614-6655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number26415
License Number StateAZ

VIII. Authorized Official

Name: KELVIN S PANESAR
Title or Position: MANAGER
Credential: MD
Phone: 480-614-6655