Provider Demographics
NPI:1083702294
Name:VEGA, MARY E (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:VEGA
Suffix:
Gender:F
Credentials:NP
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Other - First Name:
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Mailing Address - Street 1:5300 S SUTTER DR
Mailing Address - Street 2:SUITE 11
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-8050
Mailing Address - Country:US
Mailing Address - Phone:928-537-9844
Mailing Address - Fax:928-537-4437
Practice Address - Street 1:5300 S SUTTER DR
Practice Address - Street 2:SUITE 11
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-8050
Practice Address - Country:US
Practice Address - Phone:928-537-9844
Practice Address - Fax:928-537-4437
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2014-04-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZAP0331363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP29760Medicare UPIN
CAGR0101240Medicaid
CAGR0101241Medicaid