Healthcare Provider Details

I. General information

NPI: 1427635408
Provider Name (Legal Business Name): PUERTO SONORA INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4653 S LAKESHORE DR STE 3
TEMPE AZ
85282-7161
US

IV. Provider business mailing address

4653 S LAKESHORE DR STE 3
TEMPE AZ
85282-7161
US

V. Phone/Fax

Practice location:
  • Phone: 480-456-8981
  • Fax: 480-456-2906
Mailing address:
  • Phone: 480-456-8981
  • Fax: 480-456-2906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LYNN PANGALLO
Title or Position: ACCOUNTING MANAGER - CREDENTIALING
Credential:
Phone: 702-375-5777