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General NPI Number Information
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NPI Number | 1003313362
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Entity Type | Organization
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Legal Business Name | WOMENS HEALTH PALACE PLLC
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Dates
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Enumeration Date | 04/12/2018
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Last Update Date | 01/23/2019
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Provider Practice Location Address
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Address Line | 1491 N ARIZONA BLVD STE 110
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City | COOLIDGE
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State | AZ
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Zip | 85128-3261
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Country | US
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Telephone | 480-250-3694
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Fax |
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Provider Business Mailing Address
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Address Line | 3924 E ANDRE AVE
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City | GILBERT
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State | AZ
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Zip | 85298-9161
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Country | US
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Telephone | 480-250-3694
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Fax |
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Authorized Official
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Title or Position | MEMBER OWNER
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Name | VIDALIA M BUTLER-POKU
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Credential | MD
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Telephone | 480-250-3694
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 33705
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License Number State | AZ
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