MEDICARE: BRIAN HERTEL PAC 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	363AS0400X	Surgical Physician Assistant	3065	AZ

General Provider Information

NPI Number	:	1841376126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIAN HERTEL PAC LLC

Provider Business Mailing Address
First Line	:	4424 E VIRGO PL
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85249-5898
Country	:	US
Telephone Number	:	480-229-7651
Fax Number	:	480-596-8522

Provider Business Practice Location Address
First Line	:	4424 E VIRGO PL
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85249-5898
Country	:	US
Telephone Number	:	480-229-7651
Fax Number	:	480-596-8522

Authorized Official
Title or Position	:	PHYCISIAN ASSISTANT
Name	:	BRIAN E. HERTEL
Credential	:	PAC
Telephone Number	:	480-229-7651

Provider Enumeration Date	:	10/28/2006
Last Update Date	:	08/09/2019

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