Individual
SHO GRANT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
5750 W THUNDERBIRD RD STE B200, GLENDALE, AZ 85306-4664
(602) 375-1700
(602) 978-1225
Mailing address
5750 W THUNDERBIRD RD, SUITE B200, GLENDALE, AZ 85306-4660
(602) 375-1700
(602) 978-1225
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Enumeration date
08/24/2016
Last updated
09/08/2016
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