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General NPI Number Information
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NPI Number | 1528600012
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Entity Type | Individual
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Provider Name | THOMAS J PEMBERTON
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Gender | Male
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Dates
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Enumeration Date | 10/16/2019
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Last Update Date | 07/28/2020
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Provider Practice Location Address
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Address Line | 618 S MADISON DR
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City | TEMPE
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State | AZ
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Zip | 85281-7248
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Country | US
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Telephone | 480-784-1514
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Fax |
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Provider Business Mailing Address
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Address Line | 11518 E APACHE TRL STE 129
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City | APACHE JUNCTION
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State | AZ
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Zip | 85120-3572
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Country | US
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Telephone | 480-317-2214
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0808X
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Taxonomy Name | Psychiatric/Mental Health Registered Nurse
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License Number | RN196326
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License Number State | AZ
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