Healthcare Provider Details

I. General information

NPI: 1003097015
Provider Name (Legal Business Name): AZGASGIRL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 05/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E SHOW LOW LAKE RD
SHOW LOW AZ
85901-7831
US

IV. Provider business mailing address

PO BOX 29211
PHOENIX AZ
85038-9211
US

V. Phone/Fax

Practice location:
  • Phone: 602-273-6770
  • Fax: 602-889-0489
Mailing address:
  • Phone: 602-273-6770
  • Fax: 602-889-0489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0268
License Number StateAZ

VIII. Authorized Official

Name: LAURA R. SKINNER
Title or Position: SOLE MEMBER
Credential: CRNA
Phone: 602-273-6770