Provider Demographics
NPI:1619640778
Name:PACE, PHILIP (PT, DPT)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:PACE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3941 E CODY AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-3005
Mailing Address - Country:US
Mailing Address - Phone:908-894-0614
Mailing Address - Fax:
Practice Address - Street 1:1972 E BASELINE RD STE 102
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1532
Practice Address - Country:US
Practice Address - Phone:480-730-0501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-31866225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLPT-31866OtherARIZONA STATE BOARD OF PHYSICAL THERAPY