Provider Demographics
NPI:1427635408
Name:PUERTO SONORA INTERNAL MEDICINE
Entity type:Organization
Organization Name:PUERTO SONORA INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTING MANAGER - CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:PANGALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-375-5777
Mailing Address - Street 1:4653 S LAKESHORE DR STE 3
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7161
Mailing Address - Country:US
Mailing Address - Phone:480-456-8981
Mailing Address - Fax:480-456-2906
Practice Address - Street 1:4653 S LAKESHORE DR STE 3
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7161
Practice Address - Country:US
Practice Address - Phone:480-456-8981
Practice Address - Fax:480-456-2906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-25
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty