Provider Demographics
NPI:1528040482
Name:DUDZIAK, DANIEL G (RPAC)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:G
Last Name:DUDZIAK
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:340 S WILLARD ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4126
Practice Address - Country:US
Practice Address - Phone:992-639-6025
Practice Address - Fax:928-634-1117
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6391363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ222212Medicaid
AZ222212Medicaid
NYR55353Medicare UPIN