=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194287250
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YISEL VIRIDIANA CARTER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2019
-----------------------------------------------------
Last Update Date | 10/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9930 W INDIAN SCHOOL RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85037-5902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-846-7558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1050 S CERISE
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85208-3195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-458-3982
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 7624
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------