Provider Demographics
NPI:1366104192
Name:AYZENSHTAT, VADIM (PT)
Entity type:Individual
Prefix:
First Name:VADIM
Middle Name:
Last Name:AYZENSHTAT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31630
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-1630
Mailing Address - Country:US
Mailing Address - Phone:520-784-6570
Mailing Address - Fax:520-784-6575
Practice Address - Street 1:2424 N WYATT DR STE 130
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6102
Practice Address - Country:US
Practice Address - Phone:520-784-6570
Practice Address - Fax:520-784-6575
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPENDING225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist