Provider Demographics
NPI:1538288618
Name:WARD, GWEN ARLA
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:ARLA
Last Name:WARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:ARLA
Other - Last Name:GURHOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:42011 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:DESERT HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-7325
Mailing Address - Country:US
Mailing Address - Phone:623-742-0313
Mailing Address - Fax:
Practice Address - Street 1:14421 N 23RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-6023
Practice Address - Country:US
Practice Address - Phone:602-347-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0806174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ558710Medicaid