Provider Demographics
NPI:1033673314
Name:FANYA, ERIC N (NURSE)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:N
Last Name:FANYA
Suffix:
Gender:M
Credentials:NURSE
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE
Mailing Address - Street 1:3029 N ALMA SCHOOL RD STE 130
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-1474
Mailing Address - Country:US
Mailing Address - Phone:480-812-3680
Mailing Address - Fax:
Practice Address - Street 1:3029 N ALMA SCHOOL RD STE 130
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-1474
Practice Address - Country:US
Practice Address - Phone:480-812-3680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP046931164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse