Basic Information
| Provider Information | |||||||||
| NPI: | 1659364396 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMEZCUA-PATINO | ||||||||
| FirstName: | LAURO | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4055 W CHANDLER BLVD | ||||||||
| Address2: | SUITE #5 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852263700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804644431 | ||||||||
| FaxNumber: | 4804642338 | ||||||||
| Practice Location | |||||||||
| Address1: | 4055 W CHANDLER BLVD | ||||||||
| Address2: | SUITE #5 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852263700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804644431 | ||||||||
| FaxNumber: | 4804642338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2005 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 17900 | AZ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 17900 | 01 | AZ | MEDICAL LICENSE | OTHER | BA1622061 | 01 | DEA NO | OTHER |