Provider Demographics
NPI:1558341362
Name:FERGUSON, ELIZABETH MARY NESSET (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARY NESSET
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 E ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-4973
Mailing Address - Country:US
Mailing Address - Phone:602-344-5608
Mailing Address - Fax:
Practice Address - Street 1:2601 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4973
Practice Address - Country:US
Practice Address - Phone:602-344-5608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46809208600000X
AZ431042086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN130124100Medicaid
MN020002020Medicare ID - Type Unspecified
I11921Medicare UPIN