Provider Demographics
NPI:1720280795
Name:MARICOPA SURGICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:MARICOPA SURGICAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:TYRRELL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:602-616-0123
Mailing Address - Street 1:8314 N 49TH DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-6307
Mailing Address - Country:US
Mailing Address - Phone:602-616-0123
Mailing Address - Fax:623-847-1140
Practice Address - Street 1:8314 N 49TH DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-6307
Practice Address - Country:US
Practice Address - Phone:602-616-0123
Practice Address - Fax:623-847-1140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN043432363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ574237Medicaid
AZS54423Medicare UPIN
AZ70198Medicare ID - Type UnspecifiedPART B