Provider Demographics
NPI:1659514594
Name:JAO-VELASQUEZ, MICHELLE AGANA (MD)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:AGANA
Last Name:JAO-VELASQUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:J
Other - Last Name:VELASQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:20940 N. TATUM BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7273
Mailing Address - Country:US
Mailing Address - Phone:480-607-0060
Mailing Address - Fax:480-607-5809
Practice Address - Street 1:20940 N. TATUM BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-7273
Practice Address - Country:US
Practice Address - Phone:480-607-0060
Practice Address - Fax:480-607-5809
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49936207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ054741Medicaid
AZ054741Medicaid