Basic Information
| Provider Information | |||||||||
| NPI: | 1255803300 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYETTE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | KEVIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 35380 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891335380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028388265 | ||||||||
| FaxNumber: | 7028043788 | ||||||||
| Practice Location | |||||||||
| Address1: | 4730 E GRANT RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857122703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202900300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2018 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | CNP220182 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.