Healthcare Provider Details

I. General information

NPI: 1043142268
Provider Name (Legal Business Name): JERRID LUJAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7525 E BROADWAY RD
MESA AZ
85208-2002
US

IV. Provider business mailing address

4247 E BETSY LN
GILBERT AZ
85296-9626
US

V. Phone/Fax

Practice location:
  • Phone: 480-981-2700
  • Fax:
Mailing address:
  • Phone: 330-501-1154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRNP340098
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: