Provider Demographics
NPI:1649437294
Name:WAGER TABAH, BONNY (RD)
Entity type:Individual
Prefix:MRS
First Name:BONNY
Middle Name:
Last Name:WAGER TABAH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 W BELL RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-2750
Mailing Address - Country:US
Mailing Address - Phone:623-242-8460
Mailing Address - Fax:623-242-8643
Practice Address - Street 1:4025 W BELL RD
Practice Address - Street 2:SUITE 6
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-2750
Practice Address - Country:US
Practice Address - Phone:623-242-8460
Practice Address - Fax:623-242-8643
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered