Healthcare Provider Details

I. General information

NPI: 1396471348
Provider Name (Legal Business Name): BRIAN MICHAEL WOOD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2022
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4951 S WHITE MOUNTAIN RD BLDG A
SHOW LOW AZ
85901-7827
US

IV. Provider business mailing address

4951 S WHITE MOUNTAIN RD BLDG A
SHOW LOW AZ
85901-7827
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-1605
  • Fax: 928-537-9581
Mailing address:
  • Phone: 928-537-6700
  • Fax: 925-537-9581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9428
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: