Provider Demographics
NPI:1639243512
Name:TARAZON, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:TARAZON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:TARAZON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2019 W VINEYARD PLAINS DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85242-6378
Mailing Address - Country:US
Mailing Address - Phone:480-655-5286
Mailing Address - Fax:
Practice Address - Street 1:2019 W VINEYARD PLAINS DR
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85242-6378
Practice Address - Country:US
Practice Address - Phone:480-655-5286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10045385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ965840OtherAHCCCS