Provider Demographics
NPI:1083927420
Name:MATHIS, TIGGER R (MSN,APN,FNP)
Entity Type:Individual
Prefix:
First Name:TIGGER
Middle Name:R
Last Name:MATHIS
Suffix:
Gender:F
Credentials:MSN,APN,FNP
Other - Prefix:
Other - First Name:TIGGER
Other - Middle Name:R
Other - Last Name:LAIRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6611 W PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-7000
Mailing Address - Country:US
Mailing Address - Phone:602-325-5580
Mailing Address - Fax:
Practice Address - Street 1:6611 W PEORIA AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-7000
Practice Address - Country:US
Practice Address - Phone:602-325-5580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11324363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV115416OtherSMA MEDICARE
NV1083927420Medicaid
NVEF052YMedicare PIN