MEDICARE: IDENTITY HORMONES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center
2	207QA0505X	Adult Medicine Physician

General Provider Information

NPI Number	:	1326642372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDENTITY HORMONES LLC

Provider Business Mailing Address
First Line	:	100 E CAMELBACK RD STE 108
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-1061
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 E CAMELBACK RD STE 108
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-1061
Country	:	US
Telephone Number	:	901-757-3643
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS OPERATIONS DIRECTOR
Name	:	AMANDA WILKINSON
Credential	:
Telephone Number	:	702-818-0446

Provider Enumeration Date	:	11/30/2020
Last Update Date	:	11/11/2024

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Directions to “IDENTITY HORMONES LLC ” Practice Location

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