Provider Demographics
NPI:1164557724
Name:MQUQWANA, SIYANDA OBED (OT)
Entity Type:Individual
Prefix:MR
First Name:SIYANDA
Middle Name:OBED
Last Name:MQUQWANA
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 W 13TH PL
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4480
Mailing Address - Country:US
Mailing Address - Phone:928-317-0128
Mailing Address - Fax:
Practice Address - Street 1:1453 N MAIN STREET
Practice Address - Street 2:SUITE F
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-627-6567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2855225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ719643OtherAHCCCS PROVIDER ID