Healthcare Provider Details

I. General information

NPI: 1437339470
Provider Name (Legal Business Name): PALM CANYON DERMATOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W CATALINA DR
YUMA AZ
85364-8112
US

IV. Provider business mailing address

350 W CATALINA DR
YUMA AZ
85364-8112
US

V. Phone/Fax

Practice location:
  • Phone: 928-344-0650
  • Fax: 928-344-3928
Mailing address:
  • Phone: 928-344-0650
  • Fax: 928-344-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number19732
License Number StateAZ

VIII. Authorized Official

Name: MR. GREGORY ANDREW ERTL
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 928-344-0650