Provider Demographics
NPI:1063492502
Name:DASSE, CARL WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:WAYNE
Last Name:DASSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 E SHEPHERD HLS
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-1124
Mailing Address - Country:US
Mailing Address - Phone:520-886-1823
Mailing Address - Fax:
Practice Address - Street 1:4175 S ALAMO AVE
Practice Address - Street 2:
Practice Address - City:DM AFB
Practice Address - State:AZ
Practice Address - Zip Code:85707-6097
Practice Address - Country:US
Practice Address - Phone:520-228-2600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6973207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE23896Medicare UPIN