Healthcare Provider Details

I. General information

NPI: 1093260473
Provider Name (Legal Business Name): PETER M MYKUT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21811 N SCOTTSDALE RD STE 120
SCOTTSDALE AZ
85255-7448
US

IV. Provider business mailing address

15410 S MOUNTAIN PKWY STE 112
PHOENIX AZ
85044-6691
US

V. Phone/Fax

Practice location:
  • Phone: 480-513-6854
  • Fax: 480-513-6897
Mailing address:
  • Phone: 480-689-5534
  • Fax: 480-706-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number26114
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number24146
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-32120
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: