Provider Demographics
NPI:1417956061
Name:DZIADEK, TAMARA (PT)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:DZIADEK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 HAZEL ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98363-2302
Mailing Address - Country:US
Mailing Address - Phone:360-417-9484
Mailing Address - Fax:
Practice Address - Street 1:1106 HAZEL ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98363-2302
Practice Address - Country:US
Practice Address - Phone:360-417-9484
Practice Address - Fax:360-417-8826
Is Sole Proprietor?:No
Enumeration Date:2005-07-16
Last Update Date:2015-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006788225100000X, 2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7093230Medicaid
WAP00209911OtherPALMETTO GBA RR MEDICAREB
WAP00209911OtherPALMETTO GBA RR MEDICAREB
WA7093230Medicaid