Healthcare Provider Details

I. General information

NPI: 1225167331
Provider Name (Legal Business Name): FEDELIA MAEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1473 N DYSART RD SUITE 100
AVONDALE AZ
85323-1548
US

IV. Provider business mailing address

11001 N BLACK CANYON HWY
PHOENIX AZ
85029-4757
US

V. Phone/Fax

Practice location:
  • Phone: 623-925-4931
  • Fax: 623-882-0839
Mailing address:
  • Phone: 602-942-4462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3440
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: