Provider Demographics
NPI:1669855193
Name:SUN VALLEY SURGICAL PHYSICIAN ASSISTANT, LLC
Entity Type:Organization
Organization Name:SUN VALLEY SURGICAL PHYSICIAN ASSISTANT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SPEER
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:623-810-7539
Mailing Address - Street 1:9031 W RUNION DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-6472
Mailing Address - Country:US
Mailing Address - Phone:623-810-7539
Mailing Address - Fax:
Practice Address - Street 1:9031 W RUNION DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-6472
Practice Address - Country:US
Practice Address - Phone:623-810-7539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3332363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q24308Medicare UPIN