Provider Demographics
NPI:1508943671
Name:DEBIAK, KATHLEEN DIANA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:DIANA
Last Name:DEBIAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:DIANA
Other - Last Name:DEBIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2550 N THUNDERBIRD CIRCLE
Mailing Address - Street 2:STE. 303
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215
Mailing Address - Country:US
Mailing Address - Phone:480-776-1603
Mailing Address - Fax:
Practice Address - Street 1:2550 N THUNDERBIRD CIRCLE
Practice Address - Street 2:STE. 303
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215
Practice Address - Country:US
Practice Address - Phone:480-776-1603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI842-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78781736Medicaid
AZ862202Medicaid
AZ862202Medicaid