MEDICARE: FAMILY PRACTICE SPECIALISTS LTD.

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	207N00000X	Dermatology Physician		AZ
2	207Q00000X	Family Medicine Physician		AZ

General Provider Information

NPI Number	:	1972563187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PRACTICE SPECIALISTS LTD.

Provider Business Mailing Address
First Line	:	4600 E SHEA BLVD STE 100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-6031
Country	:	US
Telephone Number	:	602-955-8700
Fax Number	:	602-553-8142

Provider Business Practice Location Address
First Line	:	4600 E SHEA BLVD STE 100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-6031
Country	:	US
Telephone Number	:	602-955-8700
Fax Number	:	602-553-8142

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK A WYSE
Credential	:	M.D.
Telephone Number	:	602-955-8700

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	09/28/2023

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