Healthcare Provider Details

I. General information

NPI: 1548397755
Provider Name (Legal Business Name): NANCY VIVIANA QUEZADA RPA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 10/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 N COFCO CENTER CT STE 290
PHOENIX AZ
85008-6462
US

IV. Provider business mailing address

PO BOX 29870
PHOENIX AZ
85038-9870
US

V. Phone/Fax

Practice location:
  • Phone: 602-631-3161
  • Fax: 602-631-3162
Mailing address:
  • Phone: 602-772-3800
  • Fax: 602-772-3801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: