Provider Demographics
NPI:1184647927
Name:NORIEGA, RUDY (PAC)
Entity Type:Individual
Prefix:MR
First Name:RUDY
Middle Name:
Last Name:NORIEGA
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5822 W HEDGEHOG PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-7395
Mailing Address - Country:US
Mailing Address - Phone:602-290-2103
Mailing Address - Fax:
Practice Address - Street 1:5410 W THUNDERBIRD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4711
Practice Address - Country:US
Practice Address - Phone:602-530-6189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2065363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S49320Medicare UPIN