Provider Demographics
NPI:1578063905
Name:VANSCODER, JUSTIN WAYNE
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WAYNE
Last Name:VANSCODER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8047 W GEORGETOWN WAY
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AZ
Mailing Address - Zip Code:85132-6864
Mailing Address - Country:US
Mailing Address - Phone:760-693-9712
Mailing Address - Fax:
Practice Address - Street 1:8047 W GEORGETOWN WAY
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85132-6864
Practice Address - Country:US
Practice Address - Phone:760-693-9712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN210742163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse