Provider Demographics
NPI:1629606983
Name:DEPREY, MARY JO (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JO
Last Name:DEPREY
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 1:925 E. MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006
Mailing Address - Country:US
Mailing Address - Phone:414-460-4514
Mailing Address - Fax:
Practice Address - Street 1:814 SAMOAN DR
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-1742
Practice Address - Country:US
Practice Address - Phone:414-460-4514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8290363L00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty