Provider Demographics
NPI:1144772229
Name:VANZANT, DAVID ROBESON (ATC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ROBESON
Last Name:VANZANT
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 STEVE YZERMAN DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-4428
Mailing Address - Country:US
Mailing Address - Phone:734-748-4519
Mailing Address - Fax:
Practice Address - Street 1:19 STEVE YZERMAN DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-4428
Practice Address - Country:US
Practice Address - Phone:734-748-4519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL4705032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer