MEDICARE: DEDRA A. WADSWORTH FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	TAP5036	AZ

General Provider Information

NPI Number	:	1205275997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEDRA A. WADSWORTH FNP

Provider Business Mailing Address
First Line	:	2929 E THOMAS RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-8034
Country	:	US
Telephone Number	:	602-470-5043
Fax Number	:	602-470-5064

Provider Business Practice Location Address
First Line	:	10240 N 31ST AVE STE 200
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-9565
Country	:	US
Telephone Number	:	602-344-2500
Fax Number	:	602-247-9500

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2013
Last Update Date	:	06/17/2013

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