Provider Demographics
NPI:1710496146
Name:SUPRAK, ELIZABETH KAY (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KAY
Last Name:SUPRAK
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 1:70 N MCCLINTOCK DR STE 4
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-3711
Mailing Address - Country:US
Mailing Address - Phone:480-464-4431
Mailing Address - Fax:480-464-2338
Practice Address - Street 1:70 N MCCLINTOCK DR STE 4
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-3711
Practice Address - Country:US
Practice Address - Phone:480-464-4431
Practice Address - Fax:480-464-2338
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6825363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ208462Medicaid