Healthcare Provider Details

I. General information

NPI: 1689914145
Provider Name (Legal Business Name): JEREMY JOHN SCHLEIBAUM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 02/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15425 N GREENWAY HAYDEN LOOP STE A-300
SCOTTSDALE AZ
85260-1204
US

IV. Provider business mailing address

15425 N GREENWAY HAYDEN LOOP STE A-300
SCOTTSDALE AZ
85260-1204
US

V. Phone/Fax

Practice location:
  • Phone: 480-607-1124
  • Fax:
Mailing address:
  • Phone: 480-607-1124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5354
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: