Basic Information
| Provider Information | |||||||||
| NPI: | 1386248078 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VA MEDICAL CENTER IN PHOENIX AZ | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12585 | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863042585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026192019 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 N US HIGHWAY 89 | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863135001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284454860 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2020 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | MYERS | ||||||||
| AuthorizedOfficialFirstName: | TRAVIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OF RESPIRATORY CARE | ||||||||
| AuthorizedOfficialTelephone: | 9284454860 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS1201X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sleep Medicine | 227900000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered |
No ID Information.