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General NPI Number Information
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NPI Number | 1952053258
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Entity Type | Individual
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Provider Name | EDDY ELKASSIS
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Gender | Male
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Dates
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Enumeration Date | 01/19/2022
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Last Update Date | 11/02/2024
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Provider Practice Location Address
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Address Line | 995 E BASELINE RD APT 2116
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City | TEMPE
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State | AZ
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Zip | 85283-1363
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Country | US
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Telephone | 810-813-5550
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Fax |
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Provider Business Mailing Address
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Address Line | 6036 JENNIFER CRES
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City | WEST BLOOMFIELD
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State | MI
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Zip | 48324-3127
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Country | US
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Telephone | 810-813-5550
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 305068
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 4704369610
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License Number State | MI
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