Basic Information
Provider Information | |||||||||
NPI: | 1619395431 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WERMERS | ||||||||
FirstName: | JOSHUA | ||||||||
MiddleName: | DANIEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2108 E THOMAS RD STE 130 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850167761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029333124 | ||||||||
FaxNumber: | 6029331820 | ||||||||
Practice Location | |||||||||
Address1: | 1919 E THOMAS RD | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850167710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029331213 | ||||||||
FaxNumber: | 6029331214 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2014 | ||||||||
LastUpdateDate: | 09/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X | 009518 | AZ | Y |   | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
ID | Type | State | Issuer | Description | 2020020215 | 01 | MO | OSTEOPATHY PHYS & SURGEON LICENSE | OTHER |