Provider Demographics
NPI:1982695615
Name:NESBIT, MARY PAT (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PAT
Last Name:NESBIT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14780 W MOUNTAIN VIEW BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7280
Mailing Address - Country:US
Mailing Address - Phone:623-374-7774
Mailing Address - Fax:855-420-6361
Practice Address - Street 1:1201 S 7TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007
Practice Address - Country:US
Practice Address - Phone:602-258-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59918363A00000X
AZ2601207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ693087Medicaid
3981220OtherEVERCARE GROUP #
AZA1U1436OtherHEALTHNET GROUP #
453051001OtherGROUP HEALTH GRP #
AZCO301824OtherMEDICARE
AZ860373636OtherHUMANA GROUP #
AZCO301824OtherMEDICARE
3981220OtherEVERCARE GROUP #