Provider Demographics
NPI:1649249236
Name:ROMERO, IVAN R (PA)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:R
Last Name:ROMERO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3309
Mailing Address - Country:US
Mailing Address - Phone:480-461-2409
Mailing Address - Fax:
Practice Address - Street 1:9305 W THOMAS RD
Practice Address - Street 2:SUITE 275
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3328
Practice Address - Country:US
Practice Address - Phone:623-327-4144
Practice Address - Fax:623-327-4140
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2988363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ859126Medicaid
Q16155Medicare UPIN
AZ859126Medicaid