Healthcare Provider Details

I. General information

NPI: 1114493517
Provider Name (Legal Business Name): LUIS E GARCIA RAMOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 E BASELINE RD STE D104
TEMPE AZ
85283-1291
US

IV. Provider business mailing address

PO BOX 17779
PHOENIX AZ
85011-0779
US

V. Phone/Fax

Practice location:
  • Phone: 480-718-0568
  • Fax:
Mailing address:
  • Phone: 480-718-0568
  • Fax: 480-307-6676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: