Healthcare Provider Details

I. General information

NPI: 1588908511
Provider Name (Legal Business Name): ANA MARTINA EGURROLA-GRADILLAS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 S 6TH AVE
TUCSON AZ
85713-3303
US

IV. Provider business mailing address

3003 N CENTRAL AVE STE 1175
PHOENIX AZ
85012-0002
US

V. Phone/Fax

Practice location:
  • Phone: 602-755-0800
  • Fax: 602-560-2721
Mailing address:
  • Phone: 888-698-6727
  • Fax: 602-564-6246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5278
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: