Provider Demographics
NPI:1629155338
Name:NABONG-NILLAS, MARISTELA Y (MD)
Entity Type:Individual
Prefix:
First Name:MARISTELA
Middle Name:Y
Last Name:NABONG-NILLAS
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 1:3033 N CENTRAL AVE STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2808
Mailing Address - Country:US
Mailing Address - Phone:623-583-3001
Mailing Address - Fax:623-583-3007
Practice Address - Street 1:1705 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-6920
Practice Address - Country:US
Practice Address - Phone:623-583-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30745208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6961002Medicaid
AZ082796Medicaid
SC307457Medicaid
NJ6961002Medicaid
SCAA51371879Medicare PIN
NJ584865OtherAETNA US-HEALTHCARE
NJ850316OtherAMERIHEALTH PPO PABS
NJ6961002Medicaid
NJ0894020000OtherAMERIHEALTH HMO/KEYSTONE/PABS
NJ1152390OtherHORIZON NJ HEALTH
NJ20381OtherUNIVERSITY HEALTH PLAN
NJCA0000047OtherAMERICHOICE
NJ1839761OtherUNITED HEALTH CARE
NJ5260958OtherCIGNA
NJP661448OtherOXFORD HEALTH PLAN D
NJ850316MB5Medicare PIN