Healthcare Provider Details

I. General information

NPI: 1154897494
Provider Name (Legal Business Name): ASHLEY MEGHAN WANZER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2018
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 S COTTONWOOD DR
TEMPE AZ
85282-3040
US

IV. Provider business mailing address

2075 S COTTONWOOD DR
TEMPE AZ
85282-3040
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112753
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA101693
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: