Provider Demographics
NPI:1164191052
Name:MATHER, CAMARAE MIKAELA (CRNA)
Entity Type:Individual
Prefix:
First Name:CAMARAE
Middle Name:MIKAELA
Last Name:MATHER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CAMARAE
Other - Middle Name:MIKAELA
Other - Last Name:BERGQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:17632 N 114TH LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-6982
Mailing Address - Country:US
Mailing Address - Phone:602-653-3012
Mailing Address - Fax:
Practice Address - Street 1:18701 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7100
Practice Address - Country:US
Practice Address - Phone:602-653-3012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ263796367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered