Basic Information
| Provider Information | |||||||||
| NPI: | 1053883371 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIDALES | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3033 N CENTRAL AVE STE 145 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235833001 | ||||||||
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| Practice Location | |||||||||
| Address1: | 306 E MONROE AVE | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853262706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778095092 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2018 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 220228 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.