Basic Information
| Provider Information | |||||||||
| NPI: | 1770801870 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MA | ||||||||
| FirstName: | IRENE | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2940 E. BANNER GATEWAY DR. | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802566444 | ||||||||
| FaxNumber: | 4802563682 | ||||||||
| Practice Location | |||||||||
| Address1: | 2940 E. BANNER GATEWAY DR. | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802566444 | ||||||||
| FaxNumber: | 4802563682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2010 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MT210927 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2086S0122X | A158679 | CA | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
No ID Information.