Healthcare Provider Details

I. General information

NPI: 1568132975
Provider Name (Legal Business Name): MAZI DARRELL CONDELEE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 09/16/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MILL AVE
TEMPE AZ
85281-6699
US

IV. Provider business mailing address

11 S CENTRAL AVE APT 1401
PHOENIX AZ
85004-2596
US

V. Phone/Fax

Practice location:
  • Phone: 480-784-5500
  • Fax:
Mailing address:
  • Phone: 616-403-8775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number264067
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: