Provider Demographics
NPI:1902390297
Name:GWARY, MAMOUN
Entity type:Individual
Prefix:
First Name:MAMOUN
Middle Name:
Last Name:GWARY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 E EMELITA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-4630
Mailing Address - Country:US
Mailing Address - Phone:703-844-1922
Mailing Address - Fax:
Practice Address - Street 1:2705 E EMELITA AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-4630
Practice Address - Country:US
Practice Address - Phone:703-844-1922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ171580Medicaid