=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952059552
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINIC ROBERT AFFUSO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2022
-----------------------------------------------------
Last Update Date | 03/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17300 N 88TH AVE
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85382-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-340-1750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31611 N 132ND DR
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85383-7958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-340-1750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5333
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------