Provider Demographics
NPI:1174503999
Name:PATHOLOGY SPECIALIST OF ARIZONA, LLP
Entity type:Organization
Organization Name:PATHOLOGY SPECIALIST OF ARIZONA, LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BEA
Authorized Official - Middle Name:
Authorized Official - Last Name:SONTHIPANYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-478-8057
Mailing Address - Street 1:PO BOX 29650
Mailing Address - Street 2:DEPT #880445
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-2210
Mailing Address - Country:US
Mailing Address - Phone:623-266-7770
Mailing Address - Fax:623-322-4639
Practice Address - Street 1:424 S 56TH ST STE 120
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-2177
Practice Address - Country:US
Practice Address - Phone:602-685-5166
Practice Address - Fax:602-685-5325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ647696Medicaid
AZZWMBNXMedicare PIN