Healthcare Provider Details

I. General information

NPI: 1205004447
Provider Name (Legal Business Name): MARCO EDGARDO ZALDIVAR RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 02/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8915 E PAMPA AVE
MESA AZ
85212-2834
US

IV. Provider business mailing address

8915 E PAMPA AVE
MESA AZ
85212-2834
US

V. Phone/Fax

Practice location:
  • Phone: 480-636-9223
  • Fax: 480-686-9223
Mailing address:
  • Phone: 480-636-9223
  • Fax: 480-686-9223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN122134
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN122134
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: