MEDICARE: IDRIS A IDRIS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	F01190538	AZ

General Provider Information

NPI Number	:	1710545355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IDRIS A IDRIS NP

Provider Business Mailing Address
First Line	:	3515 W UNION HILLS DR STE 111
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-2430
Country	:	US
Telephone Number	:	623-328-8630
Fax Number	:	623-243-7842

Provider Business Practice Location Address
First Line	:	3515 W UNION HILLS DR STE 111
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-2430
Country	:	US
Telephone Number	:	623-328-8630
Fax Number	:	623-243-7842

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2019
Last Update Date	:	07/22/2019

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