Provider Demographics
NPI:1760044325
Name:PLASTIC AND PERIPHERAL NERVE SURGERY LLC
Entity Type:Organization
Organization Name:PLASTIC AND PERIPHERAL NERVE SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-802-8511
Mailing Address - Street 1:25229 S SUN LAKES BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:SUN LAKES
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-6465
Mailing Address - Country:US
Mailing Address - Phone:480-802-8511
Mailing Address - Fax:480-802-8129
Practice Address - Street 1:25229 S SUN LAKES BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SUN LAKES
Practice Address - State:AZ
Practice Address - Zip Code:85248-6465
Practice Address - Country:US
Practice Address - Phone:480-802-8511
Practice Address - Fax:480-802-8129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-03
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty