Provider Demographics
NPI:1093054231
Name:KEDEM, YAWTVAW DEETZAW
Entity Type:Individual
Prefix:
First Name:YAWTVAW
Middle Name:DEETZAW
Last Name:KEDEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3619 E PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-3699
Mailing Address - Country:US
Mailing Address - Phone:480-907-9732
Mailing Address - Fax:
Practice Address - Street 1:3619 E PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-3699
Practice Address - Country:US
Practice Address - Phone:480-907-9732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10159A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant