=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174013270
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANYON SKY ENT PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2018
-----------------------------------------------------
Last Update Date | 10/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2151 E PECOS RD STE 1
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85225-6098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-676-3322
-----------------------------------------------------
Fax | 480-676-3523
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2151 E PECOS RD STE 1
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85225-6098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-676-3322
-----------------------------------------------------
Fax | 480-676-3523
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MAULIK B. SHAH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 480-676-3322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 41072
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------