Healthcare Provider Details

I. General information

NPI: 1447676572
Provider Name (Legal Business Name): PASSPORT HEALTH HOLDINGS, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2014
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 UNIVERSITY AVENUE W SUITE 207
SAINT PAUL MN
55104
US

IV. Provider business mailing address

668 N 44TH ST SUITE 100W
PHOENIX AZ
85008
US

V. Phone/Fax

Practice location:
  • Phone: 877-358-8648
  • Fax: 877-877-6875
Mailing address:
  • Phone: 877-358-8648
  • Fax: 877-877-6875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number261Q0000X
License Number StateMN

VIII. Authorized Official

Name: MR. PAUL FISHBURN
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 480-646-9020