MEDICARE: IDORENYIN PHILIP NP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	282721	AZ

General Provider Information

NPI Number	:	1639886583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IDORENYIN PHILIP NP

Provider Business Mailing Address
First Line	:	9015 W UNION HILLS DR STE 107
Second Line	:	#344
City	:	PEORIA
State	:	AZ
Zip	:	85382
Country	:	US
Telephone Number	:	480-256-2669
Fax Number	:

Provider Business Practice Location Address
First Line	:	1407 S 9TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85007-3904
Country	:	US
Telephone Number	:	602-975-6155
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2022
Last Update Date	:	10/31/2022

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