Provider Demographics
NPI:1639330566
Name:ADVANCED PLASTIC RECONSTRUCTION PLLC
Entity Type:Organization
Organization Name:ADVANCED PLASTIC RECONSTRUCTION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PABLO
Authorized Official - Middle Name:A
Authorized Official - Last Name:PRICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-331-7811
Mailing Address - Street 1:PO BOX 47490
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85068-7490
Mailing Address - Country:US
Mailing Address - Phone:602-331-7811
Mailing Address - Fax:602-331-5886
Practice Address - Street 1:9250 N 3RD ST
Practice Address - Street 2:SUITE 1003
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2402
Practice Address - Country:US
Practice Address - Phone:602-331-7811
Practice Address - Fax:602-331-5886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-23
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z124156OtherMEDICARE PTAN
AZ358484Medicaid