Provider Demographics
NPI:1124192372
Name:NIBLEY, MEGAN JOY (PA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:JOY
Last Name:NIBLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 E MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2612
Mailing Address - Country:US
Mailing Address - Phone:602-839-5097
Mailing Address - Fax:602-839-3075
Practice Address - Street 1:1111 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2612
Practice Address - Country:US
Practice Address - Phone:602-839-5097
Practice Address - Fax:602-839-3075
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1074834363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZIN PROCESSMedicaid
IN PROCESSMedicare ID - Type Unspecified