Basic Information
| Provider Information | |||||||||
| NPI: | 1154437317 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOBACK | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | ALLAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 N CENTRAL AVE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023233344 | ||||||||
| FaxNumber: | 6023233496 | ||||||||
| Practice Location | |||||||||
| Address1: | 3830 E VAN BUREN ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850086920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022437277 | ||||||||
| FaxNumber: | 6022860808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 6371A | WY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 51526 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 115373100 | 05 | WY | MEDICAID | 111718 | 05 | AZ | MEDICAID |