Provider Demographics
NPI:1003857301
Name:MINERS, MARY LYNN (NP)
Entity Type:Individual
Prefix:
First Name:MARY LYNN
Middle Name:
Last Name:MINERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 E RIVER RD
Mailing Address - Street 2:350
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-5999
Mailing Address - Country:US
Mailing Address - Phone:520-519-7720
Mailing Address - Fax:520-519-5181
Practice Address - Street 1:6565 E CARONDELET DR
Practice Address - Street 2:STE 155
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3587
Practice Address - Country:US
Practice Address - Phone:520-886-0206
Practice Address - Fax:520-886-0829
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN089032363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ527202Medicaid
AZ86-0938204OtherTIN
AZ527202Medicaid
AZZ63355Medicare PIN
AZZ130578Medicare PIN