Provider Demographics
NPI:1053491878
Name:MAYORGA, ROGER M (APN)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:M
Last Name:MAYORGA
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E EARLL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2634
Mailing Address - Country:US
Mailing Address - Phone:602-808-2800
Mailing Address - Fax:
Practice Address - Street 1:40 E MITCHELL DR
Practice Address - Street 2:SUITE 100 & 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2330
Practice Address - Country:US
Practice Address - Phone:602-808-5800
Practice Address - Fax:602-248-7993
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8136363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ269427Medicaid
AZZ119547Medicare PIN