Healthcare Provider Details

I. General information

NPI: 1871065896
Provider Name (Legal Business Name): LAURA MATHER PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9520 W PALM LN STE 115
PHOENIX AZ
85037-4403
US

IV. Provider business mailing address

1450 S DOBSON RD STE A200
MESA AZ
85202-4742
US

V. Phone/Fax

Practice location:
  • Phone: 480-556-0446
  • Fax: 480-556-0447
Mailing address:
  • Phone: 480-629-5167
  • Fax: 480-912-1068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7260
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: