Provider Demographics
NPI:1639543523
Name:CUMMINS, WAYNE
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:CUMMINS
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 1:1475 N WILMOT RD APT 35
Mailing Address - Street 2:TUCSON
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-4452
Mailing Address - Country:US
Mailing Address - Phone:520-519-9380
Mailing Address - Fax:
Practice Address - Street 1:1475 N WILMOT RD APT 35
Practice Address - Street 2:TUCSON
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-4452
Practice Address - Country:US
Practice Address - Phone:520-519-9380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-4708385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH-4708OtherAZ DEPT OF HEALTH SVCS