Provider Demographics
NPI:1639560816
Name:MINTZ, ROSE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARIE
Last Name:MINTZ
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 1:312 N ALMA SCHOOL RD STE 11
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-4354
Mailing Address - Country:US
Mailing Address - Phone:623-300-5477
Mailing Address - Fax:
Practice Address - Street 1:9015 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2444
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:602-714-3755
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-10
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
AZ5991363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ467439Medicaid