Provider Demographics
NPI:1528216371
Name:TARDIF, MAURA BRIDGET (PA-C)
Entity Type:Individual
Prefix:
First Name:MAURA
Middle Name:BRIDGET
Last Name:TARDIF
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 1:5505 W CHANDLER BLVD STE B13
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-3681
Mailing Address - Country:US
Mailing Address - Phone:480-361-4780
Mailing Address - Fax:480-361-4781
Practice Address - Street 1:5505 W CHANDLER BLVD STE B13
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-3681
Practice Address - Country:US
Practice Address - Phone:480-361-4780
Practice Address - Fax:480-361-4781
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
AZAZ4421363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ439087Medicaid