Healthcare Provider Details

I. General information

NPI: 1649728981
Provider Name (Legal Business Name): PAUL KOURY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13600 REBONITO CT NE
ALBUQUERQUE NM
87112-4929
US

IV. Provider business mailing address

4427 W PARK VIEW LN
GLENDALE AZ
85310-0004
US

V. Phone/Fax

Practice location:
  • Phone: 505-980-2578
  • Fax:
Mailing address:
  • Phone: 505-980-2578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704324213
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number285173
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: