Provider Demographics
NPI:1689411555
Name:URSIN-ZACHARY, DEEADRA LYNANIA (CRANIAL PROTHESIS)
Entity type:Individual
Prefix:
First Name:DEEADRA
Middle Name:LYNANIA
Last Name:URSIN-ZACHARY
Suffix:
Gender:F
Credentials:CRANIAL PROTHESIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1867 RAINBOW CIR
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7020
Mailing Address - Country:US
Mailing Address - Phone:928-200-3131
Mailing Address - Fax:
Practice Address - Street 1:2707 S WHITE MOUNTAIN RD STE G
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7343
Practice Address - Country:US
Practice Address - Phone:928-421-0998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier