Healthcare Provider Details

I. General information

NPI: 1952053258
Provider Name (Legal Business Name): EDDY ELKASSIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 11/02/2024
Certification Date: 11/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 E BASELINE RD APT 2116
TEMPE AZ
85283-1363
US

IV. Provider business mailing address

6036 JENNIFER CRES
WEST BLOOMFIELD MI
48324-3127
US

V. Phone/Fax

Practice location:
  • Phone: 810-813-5550
  • Fax:
Mailing address:
  • Phone: 810-813-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number305068
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704369610
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: