Provider Demographics
NPI:1619554789
Name:VASQUEZ, EDWIN (ATC/LAT)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21802 W SONORA ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-8010
Mailing Address - Country:US
Mailing Address - Phone:623-224-1422
Mailing Address - Fax:
Practice Address - Street 1:21802 W SONORA ST
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-8010
Practice Address - Country:US
Practice Address - Phone:623-224-1422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZATR-0093292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer