Provider Demographics
NPI:1942905443
Name:FEDOR, DYLAN GEORGE
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:GEORGE
Last Name:FEDOR
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 1:318 W VERANO PL
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-7330
Mailing Address - Country:US
Mailing Address - Phone:480-226-8427
Mailing Address - Fax:
Practice Address - Street 1:311 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3125
Practice Address - Country:US
Practice Address - Phone:870-972-0063
Practice Address - Fax:870-930-2914
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program