Provider Demographics
NPI:1225167331
Name:MAEZ, FEDELIA (PA-C)
Entity Type:Individual
Prefix:
First Name:FEDELIA
Middle Name:
Last Name:MAEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11001 N BLACK CANYON HWY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4757
Mailing Address - Country:US
Mailing Address - Phone:602-942-4462
Mailing Address - Fax:
Practice Address - Street 1:1473 N DYSART RD
Practice Address - Street 2:SUITE 100
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-1548
Practice Address - Country:US
Practice Address - Phone:623-925-4931
Practice Address - Fax:623-882-0839
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ194907Medicaid
AZZWCKJNMedicare PIN
AZZWCKHGMedicare PIN
AZ194907Medicaid