Provider Demographics
NPI:1235863465
Name:TAVRYTZKY, MARY KATELIN
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATELIN
Last Name:TAVRYTZKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3202 W CASINO AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-5893
Mailing Address - Country:US
Mailing Address - Phone:623-215-5609
Mailing Address - Fax:
Practice Address - Street 1:3202 W CASINO AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85083-5893
Practice Address - Country:US
Practice Address - Phone:623-215-5609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
AZ9979363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program