Basic Information
| Provider Information | |||||||||
| NPI: | 1316347776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DALLAS | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | KAMERON | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2910 N 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807670555 | ||||||||
| FaxNumber: | 4807043373 | ||||||||
| Practice Location | |||||||||
| Address1: | 10245 N 92ND ST | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807670555 | ||||||||
| FaxNumber: | 4807043373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2014 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | LPT-011036 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 964662 | 05 | AZ | MEDICAID |