=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982064515
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TODD ROBERT SHORTEN NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2016
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6153 W OLIVE AVE
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85302-4564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-685-6000
-----------------------------------------------------
Fax | 623-937-2589
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3003 N CENTRAL AVE STE 200
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85012-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-685-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | AP10286
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------