Provider Demographics
NPI:1184175432
Name:TICSAY, RENE VENZON (RT)
Entity type:Individual
Prefix:MR
First Name:RENE
Middle Name:VENZON
Last Name:TICSAY
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15951 W COCOPAH ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-7930
Mailing Address - Country:US
Mailing Address - Phone:928-697-4306
Mailing Address - Fax:928-697-4107
Practice Address - Street 1:KAYENTA HEALTH CENTER HIGHWAY 160
Practice Address - Street 2:
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033
Practice Address - Country:US
Practice Address - Phone:928-697-4306
Practice Address - Fax:928-697-4107
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ142562471C3402X
MN2718152471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography