Provider Demographics
NPI:1114992179
Name:DUTKIEWICZ, JAMES W (PA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:DUTKIEWICZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4000
Mailing Address - Fax:
Practice Address - Street 1:2121 W IRONWOOD CENTER DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2639
Practice Address - Country:US
Practice Address - Phone:208-625-4680
Practice Address - Fax:208-625-4681
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8299141Medicaid
R34082Medicare UPIN
ID1665166Medicare ID - Type Unspecified
ID805073300Medicaid