Provider Demographics
NPI:1538445812
Name:MODOCUROGYN, PLLC
Entity type:Organization
Organization Name:MODOCUROGYN, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISETTE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:HAWN
Authorized Official - Suffix:
Authorized Official - Credentials:PRACTICE MANAGER
Authorized Official - Phone:480-889-2654
Mailing Address - Street 1:6632 E. BASELINE RD
Mailing Address - Street 2:STE 101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206
Mailing Address - Country:US
Mailing Address - Phone:480-889-2654
Mailing Address - Fax:480-699-1022
Practice Address - Street 1:6632 E. BASELINE RD
Practice Address - Street 2:STE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:480-889-2654
Practice Address - Fax:480-699-1022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ094866Medicaid
AZ663388Medicaid
AZ663388Medicaid
AZZ143114Medicare PIN
AZ094866Medicaid