Provider Demographics
NPI:1063951614
Name:MAYBORNE, PATRICIA (NP)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:MAYBORNE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 N 24TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-4645
Mailing Address - Country:US
Mailing Address - Phone:602-844-7246
Mailing Address - Fax:602-759-7246
Practice Address - Street 1:1401 N 24TH ST STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4645
Practice Address - Country:US
Practice Address - Phone:602-844-7246
Practice Address - Fax:602-759-7246
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP9657363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ250048Medicaid