Provider Demographics
NPI:1669091534
Name:GIPSON, MARYKA MADELL
Entity type:Individual
Prefix:
First Name:MARYKA
Middle Name:MADELL
Last Name:GIPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARYKA
Other - Middle Name:MADELL
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5003 W FALLEN LEAF LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-3002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14044 W CAMELBACK RD STE 118
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-9481
Practice Address - Country:US
Practice Address - Phone:623-547-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty