Provider Demographics
NPI:1679298970
Name:ROBLES PHAN, JHAMIEL MELCHIZEDEK TAMBA
Entity type:Individual
Prefix:
First Name:JHAMIEL MELCHIZEDEK
Middle Name:TAMBA
Last Name:ROBLES PHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JHAMIEL MELCHIZEDEK
Other - Middle Name:TAMBA
Other - Last Name:ROBLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7027 W SOUTHGATE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-6611
Mailing Address - Country:US
Mailing Address - Phone:928-210-1002
Mailing Address - Fax:
Practice Address - Street 1:1111 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2612
Practice Address - Country:US
Practice Address - Phone:928-210-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ281933367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered