Provider Demographics
NPI:1437146198
Name:ZAJICEK, DANIEL W (PAC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:W
Last Name:ZAJICEK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1844
Mailing Address - Country:US
Mailing Address - Phone:920-730-6700
Mailing Address - Fax:
Practice Address - Street 1:1611 S MADISON ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1844
Practice Address - Country:US
Practice Address - Phone:920-730-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-28
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI581363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42928200Medicaid
WI42928200Medicaid
R97700Medicare UPIN
WI0454 45300Medicare PIN