Healthcare Provider Details

I. General information

NPI: 1528600012
Provider Name (Legal Business Name): THOMAS J PEMBERTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2019
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 S MADISON DR
TEMPE AZ
85281-7248
US

IV. Provider business mailing address

11518 E APACHE TRL STE 129
APACHE JUNCTION AZ
85120-3572
US

V. Phone/Fax

Practice location:
  • Phone: 480-784-1514
  • Fax:
Mailing address:
  • Phone: 480-317-2214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN196326
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: