Healthcare Provider Details

I. General information

NPI: 1831469733
Provider Name (Legal Business Name): VINCENT M. NORIEGA FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2919 S ELLSWORTH RD STE 102
MESA AZ
85212-2165
US

IV. Provider business mailing address

2919 S ELLSWORTH RD STE 102
MESA AZ
85212-2165
US

V. Phone/Fax

Practice location:
  • Phone: 480-354-2008
  • Fax: 480-907-1322
Mailing address:
  • Phone: 480-354-2008
  • Fax: 480-907-1322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP4338
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: