Provider Demographics
NPI:1710545355
Name:IDRIS, IDRIS A (NP)
Entity Type:Individual
Prefix:
First Name:IDRIS
Middle Name:A
Last Name:IDRIS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 W UNION HILLS DR STE 111
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-2430
Mailing Address - Country:US
Mailing Address - Phone:623-328-8630
Mailing Address - Fax:623-243-7842
Practice Address - Street 1:3515 W UNION HILLS DR STE 111
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-2430
Practice Address - Country:US
Practice Address - Phone:623-328-8630
Practice Address - Fax:623-243-7842
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZF01190538363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily