Healthcare Provider Details

I. General information

NPI: 1629606983
Provider Name (Legal Business Name): MARY JO DEPREY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 E MCDOWELL RD
PHOENIX AZ
85006-2502
US

IV. Provider business mailing address

925 E. MCDOWELL RD
PHOENIX AZ
85006
US

V. Phone/Fax

Practice location:
  • Phone: 602-521-3700
  • Fax:
Mailing address:
  • Phone: 414-460-4514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8290
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8290
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: