Healthcare Provider Details

I. General information

NPI: 1275099020
Provider Name (Legal Business Name): DAVID MEDANSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11980 W SHIFTING SANDS DR
PEORIA AZ
85383-2623
US

IV. Provider business mailing address

11980 W SHIFTING SANDS DR
PEORIA AZ
85383-2623
US

V. Phone/Fax

Practice location:
  • Phone: 602-721-5218
  • Fax:
Mailing address:
  • Phone: 602-721-5218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: