Provider Demographics
NPI:1023667862
Name:VAZQUEZ, MARIO (NP)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:WALDO
Other - Middle Name:MARIO
Other - Last Name:VAZQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2400 S AVENUE A
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364
Mailing Address - Country:US
Mailing Address - Phone:928-344-2000
Mailing Address - Fax:
Practice Address - Street 1:2451 S AVENUE A STE A104
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7189
Practice Address - Country:US
Practice Address - Phone:928-336-2165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ234060363LA2100X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ600512Medicaid