Provider Demographics
NPI:1033201405
Name:TAGLE, FATIMA CABAL (NP)
Entity Type:Individual
Prefix:
First Name:FATIMA
Middle Name:CABAL
Last Name:TAGLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:FATIMA
Other - Middle Name:CASTANAR
Other - Last Name:CABAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21618 N 44TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-6934
Mailing Address - Country:US
Mailing Address - Phone:480-513-0793
Mailing Address - Fax:480-513-0793
Practice Address - Street 1:3202 E GREENWAY RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4548
Practice Address - Country:US
Practice Address - Phone:602-325-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0002138-C-NP363LG0600X
AZAP3316363LG0600X
MI4704203126363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI470246910Medicaid
MI470247810Medicaid
MIFC203126OtherBLUE SHIELD
MIP00231988OtherRR MEDICARE
MIP11300004Medicare ID - Type Unspecified
MIP00231988OtherRR MEDICARE
MI470247810Medicaid