Provider Demographics
NPI:1063484517
Name:ROLDAN, GLADYS (PA)
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:
Last Name:ROLDAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GLADYS
Other - Middle Name:
Other - Last Name:CONTRERAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:4600 S MILL AVE
Mailing Address - Street 2:STE 280
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-6850
Mailing Address - Country:US
Mailing Address - Phone:480-305-2888
Mailing Address - Fax:480-305-2889
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ993338Medicaid
AZ993338Medicaid