Basic Information
| Provider Information | |||||||||
| NPI: | 1750690335 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STRAWN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | BRENT | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19420 N 59TH AVE | ||||||||
| Address2: | SUITE B233 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853086894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232342542 | ||||||||
| FaxNumber: | 6232342543 | ||||||||
| Practice Location | |||||||||
| Address1: | 9515 W CAMELBACK RD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235818346 | ||||||||
| FaxNumber: | 6235818347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2010 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 27620 | AZ | N | Other Service Providers | Specialist | 208D00000X | 27620 | AZ | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 273316090 | 01 | AZ | TAX ID | OTHER |