Healthcare Provider Details

I. General information

NPI: 1114600368
Provider Name (Legal Business Name): JOHN CALVIN ZAMBRANO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 08/14/2023
Certification Date: 08/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11030 E TARRAGON AVE
MESA AZ
85212-8233
US

IV. Provider business mailing address

11030 E TARRAGON AVE
MESA AZ
85212-8233
US

V. Phone/Fax

Practice location:
  • Phone: 808-428-6997
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN091710
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN091710
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: