Provider Demographics
NPI:1578633657
Name:PRENDERGAST, VIRGINIA (NP)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2358
Mailing Address - Country:US
Mailing Address - Phone:480-220-4688
Mailing Address - Fax:602-406-4969
Practice Address - Street 1:1424 E MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2358
Practice Address - Country:US
Practice Address - Phone:480-220-4688
Practice Address - Fax:602-406-4969
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN039088163W00000X
AZAP6877363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ179864Medicare PIN