Provider Demographics
NPI:1972563187
Name:FAMILY PRACTICE SPECIALISTS LTD.
Entity type:Organization
Organization Name:FAMILY PRACTICE SPECIALISTS LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:WYSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-955-8700
Mailing Address - Street 1:4600 E SHEA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6031
Mailing Address - Country:US
Mailing Address - Phone:602-955-8700
Mailing Address - Fax:602-553-8142
Practice Address - Street 1:4600 E SHEA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6031
Practice Address - Country:US
Practice Address - Phone:602-955-8700
Practice Address - Fax:602-553-8142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207N00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWCHDFMedicare PIN