Basic Information
| Provider Information | |||||||||
| NPI: | 1053491878 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAYORGA | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 E EARLL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028082800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 E MITCHELL DR | ||||||||
| Address2: | SUITE 100 & 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028085800 | ||||||||
| FaxNumber: | 6022487993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | AP8136 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 269427 | 05 | AZ | MEDICAID |