Provider Demographics
NPI:1386349207
Name:VANNASDALE, ROBERT JAY SR
Entity type:Individual
Prefix:
First Name:ROBERT JAY
Middle Name:
Last Name:VANNASDALE
Suffix:SR
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 1:53626 W STARGAZER RD
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85139-2750
Mailing Address - Country:US
Mailing Address - Phone:520-252-2330
Mailing Address - Fax:
Practice Address - Street 1:5131 E CLOUD RD
Practice Address - Street 2:
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-9063
Practice Address - Country:US
Practice Address - Phone:520-252-2330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide