Basic Information
| Provider Information | |||||||||
| NPI: | 1588830749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONTRERAS | ||||||||
| FirstName: | LUPE | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4041 N CENTRAL AVE BLDG C | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850123313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022795262 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4041 N CENTRAL AVE BLDG C | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850123313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022795262 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2008 | ||||||||
| LastUpdateDate: | 03/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP8845 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 3007734 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 3007734 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 790321 | 05 | AZ | MEDICAID |