Provider Demographics
NPI:1093791568
Name:KANWISCHER, AUDREY A (DO)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:A
Last Name:KANWISCHER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247-0115
Mailing Address - Country:US
Mailing Address - Phone:602-528-1340
Mailing Address - Fax:602-528-1296
Practice Address - Street 1:483 W. SEED FARM RD.
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247
Practice Address - Country:US
Practice Address - Phone:602-528-1340
Practice Address - Fax:602-528-1296
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37442084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH61393Medicare UPIN