Provider Demographics
NPI:1477050615
Name:WAYNE, ROBERT (BOCO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WAYNE
Suffix:
Gender:M
Credentials:BOCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18140 W PURDUE AVE
Mailing Address - Street 2:
Mailing Address - City:WADDELL
Mailing Address - State:AZ
Mailing Address - Zip Code:85355-4237
Mailing Address - Country:US
Mailing Address - Phone:602-320-4521
Mailing Address - Fax:
Practice Address - Street 1:18140 W PURDUE AVE
Practice Address - Street 2:
Practice Address - City:WADDELL
Practice Address - State:AZ
Practice Address - Zip Code:85355-4237
Practice Address - Country:US
Practice Address - Phone:602-320-4521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZC15463222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist