Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0120X | Pediatric Surgery | 34139 | AZ |
NPI | 1003818642 |
---|---|
Provider Name | Ms. Kathleen Dolores Van Leeuwen |
First Address | Phoenix, AZ 85018-2327 |
Second Address | Phoenix, AZ 85016-7710 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2005 |
Last Update Date | 29/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
940610 | (05) | AZ |
Z188395 | (02) | AZ |