Provider Demographics
NPI:1467433839
Name:WODIUK, GWEN ANNETTE (DNP, FNP)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:ANNETTE
Last Name:WODIUK
Suffix:
Gender:F
Credentials:DNP, FNP
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:ANNETTE
Other - Last Name:WODIUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19389 N 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6500
Mailing Address - Country:US
Mailing Address - Phone:623-537-6000
Mailing Address - Fax:623-537-6014
Practice Address - Street 1:19389 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6500
Practice Address - Country:US
Practice Address - Phone:623-537-6000
Practice Address - Fax:623-537-6014
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2280363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ977861Medicaid
AZZ106775Medicare PIN
AZP00286610Medicare PIN
AZ977861Medicaid
AZZ106776Medicare PIN