Provider Demographics
NPI:1124501069
Name:GRAND CANYON UNIVERSITY
Entity type:Organization
Organization Name:GRAND CANYON UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:602-639-7757
Mailing Address - Street 1:3300 W CAMELBACK RD
Mailing Address - Street 2:HEALTH CENTER
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-1097
Mailing Address - Country:US
Mailing Address - Phone:602-639-6215
Mailing Address - Fax:602-639-7830
Practice Address - Street 1:3300 W CAMELBACK RD
Practice Address - Street 2:HEALTH CENTER
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-1097
Practice Address - Country:US
Practice Address - Phone:602-639-6215
Practice Address - Fax:602-639-7830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-06
Last Update Date:2021-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC9096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty