Individual
JASON BANUELOS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
435 N 5TH ST, PHOENIX, AZ 85004-2157
(602) 827-2450
Mailing address
12217 N 129TH DR, EL MIRAGE, AZ 85335-6270
(623) 414-8631
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
9366
AZ
Other
Enumeration date
06/03/2022
Last updated
12/12/2023
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