Healthcare Provider Details

I. General information

NPI: 1497947816
Provider Name (Legal Business Name): MARIA CONKLIN COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 05/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4113 W ORAIBI DR
GLENDALE AZ
85308-7424
US

IV. Provider business mailing address

13835 N TATUM BLVD STE 9-429
PHOENIX AZ
85032-5590
US

V. Phone/Fax

Practice location:
  • Phone: 602-614-6683
  • Fax:
Mailing address:
  • Phone: 480-204-7475
  • Fax: 602-633-1076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1744
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: