Provider Demographics
NPI: | 1700254802 |
---|---|
Name: | DE GUZMAN, MARIA VICTORIA |
Entity Type: | Individual |
Prefix: | |
First Name: | MARIA VICTORIA |
Middle Name: | |
Last Name: | DE GUZMAN |
Suffix: | |
Gender: | F |
Credentials: | |
Other - Prefix: | |
Other - First Name: | MARIA |
Other - Middle Name: | |
Other - Last Name: | DE GUZMAN |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | |
Mailing Address - Street 1: | 3003 N CENTRAL AVE STE 200 |
Mailing Address - Street 2: | |
Mailing Address - City: | PHOENIX |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85012-2914 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 602-323-3344 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 140 N LITCHFIELD RD STE 200 |
Practice Address - Street 2: | |
Practice Address - City: | GOODYEAR |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85338-1226 |
Practice Address - Country: | US |
Practice Address - Phone: | 602-243-7277 |
Practice Address - Fax: | 623-247-9742 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2015-09-04 |
Last Update Date: | 2020-05-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | AP8111 | 363L00000X, 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AZ | 075672 | Medicaid |