Provider Demographics
NPI:1134166499
Name:CODY, BRIAN (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CODY
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20950 N TATUM BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4204
Mailing Address - Country:US
Mailing Address - Phone:480-222-7246
Mailing Address - Fax:480-222-7271
Practice Address - Street 1:4025 W CHANDLER BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226
Practice Address - Country:US
Practice Address - Phone:480-222-7246
Practice Address - Fax:480-222-7271
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2025-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ80894Medicare PIN