Healthcare Provider Details

I. General information

NPI: 1619412921
Provider Name (Legal Business Name): COURTNEY R KENYON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2016
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5499
US

IV. Provider business mailing address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5499
US

V. Phone/Fax

Practice location:
  • Phone: 480-301-8000
  • Fax:
Mailing address:
  • Phone: 480-301-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7802
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1803
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: