=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407565906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESUS RYAN ARVIZO JR. FNP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2022
-----------------------------------------------------
Last Update Date | 12/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 239 N LITCHFIELD RD
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85338-1249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-549-8865
-----------------------------------------------------
Fax | 520-391-2936
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12317 W LARKSPUR RD
-----------------------------------------------------
City | EL MIRAGE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85335-5286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-296-6682
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WW0000X
-----------------------------------------------------
Taxonomy Name | Wound Care Registered Nurse
-----------------------------------------------------
License Number | 241088
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 241088
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 241088
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 241088
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------