Provider Demographics
NPI:1265485130
Name:MEDLEY, MARISSA QUIJANO (PT)
Entity Type:Individual
Prefix:MISS
First Name:MARISSA
Middle Name:QUIJANO
Last Name:MEDLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:ASHLEY
Other - Last Name:QUIJANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5777 E MAYO BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-4502
Mailing Address - Country:US
Mailing Address - Phone:480-301-8000
Mailing Address - Fax:
Practice Address - Street 1:5777 E MAYO BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054-4502
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7006225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ223879Medicaid
AZP00625153OtherRAILROAD MEDICARE
AZ223879Medicaid
AZP00625153OtherRAILROAD MEDICARE
AZ106932Medicare ID - Type Unspecified