Provider Demographics
NPI:1760929152
Name:SAN ROMAN, TALIA K (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:TALIA
Middle Name:K
Last Name:SAN ROMAN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9375 E SHEA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6986
Mailing Address - Country:US
Mailing Address - Phone:833-695-4673
Mailing Address - Fax:
Practice Address - Street 1:9375 E SHEA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6986
Practice Address - Country:US
Practice Address - Phone:833-695-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020029685363LP0808X
KS53-77526-082363LP0808X
AZAP9981363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100240930AMedicaid