Provider Demographics
NPI:1235995853
Name:BEJARANO, MARIYAH MARISELLA
Entity Type:Individual
Prefix:
First Name:MARIYAH
Middle Name:MARISELLA
Last Name:BEJARANO
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 1:1844 N ELOISA LN
Mailing Address - Street 2:
Mailing Address - City:THATCHER
Mailing Address - State:AZ
Mailing Address - Zip Code:85552-5581
Mailing Address - Country:US
Mailing Address - Phone:520-850-0472
Mailing Address - Fax:
Practice Address - Street 1:1300 S 20TH AVE
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-3301
Practice Address - Country:US
Practice Address - Phone:928-428-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ304177363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily