=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457946964
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAWANVIR SINGH TUNG PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2021
-----------------------------------------------------
Last Update Date | 05/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5620 W THUNDERBIRD RD STE B3
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85306-4638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-206-6262
-----------------------------------------------------
Fax | 602-206-6262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5620 W THUNDERBIRD RD STE B3
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85306-4638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-206-6262
-----------------------------------------------------
Fax | 602-235-0296
-----------------------------------------------------
=====================================================
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 | 8674
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------