Provider Demographics
NPI:1124415773
Name:MINAFEE, TANYA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:MINAFEE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1343 N ALMA SCHOOL RD
Mailing Address - Street 2:STE 160
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5901
Mailing Address - Country:US
Mailing Address - Phone:602-773-5600
Mailing Address - Fax:602-773-5601
Practice Address - Street 1:1108 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ- ARIZONA
Practice Address - Zip Code:85013
Practice Address - Country:UM
Practice Address - Phone:602-773-5600
Practice Address - Fax:602-773-5601
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-22
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7793363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ055773Medicaid
AZZ180729OtherPTAN