Provider Demographics
NPI:1932215407
Name:MARCUZZO, VIVIAN M (PA)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:M
Last Name:MARCUZZO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6112 E BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4955
Mailing Address - Country:US
Mailing Address - Phone:480-448-0244
Mailing Address - Fax:480-924-4140
Practice Address - Street 1:2730 S VAL VISTA DR
Practice Address - Street 2:SUITE 187
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1675
Practice Address - Country:US
Practice Address - Phone:480-324-0300
Practice Address - Fax:480-324-0324
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17936363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17938Medicaid
P00281443OtherRAILROAD MEDICARE
CAPA17938Medicaid
CAWPA17938AMedicare ID - Type UnspecifiedPHYSICIAN ASSISTANT