Provider Demographics
NPI:1891155875
Name:VANWOESIK, EDWARD W (ACNP-BC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:W
Last Name:VANWOESIK
Suffix:
Gender:M
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15417 N 170TH AVE
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-1321
Mailing Address - Country:US
Mailing Address - Phone:623-326-2787
Mailing Address - Fax:
Practice Address - Street 1:14961 W BELL RD STE 175
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3220
Practice Address - Country:US
Practice Address - Phone:623-242-9830
Practice Address - Fax:623-243-6733
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8508363LA2100X
AZRN150175207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ133428Medicaid
AZZ188653Medicare UPIN