Provider Demographics
NPI:1932503802
Name:ONDOVCHAK, FREDERIC LELAND (RN, MSN, APR)
Entity Type:Individual
Prefix:MR
First Name:FREDERIC
Middle Name:LELAND
Last Name:ONDOVCHAK
Suffix:
Gender:M
Credentials:RN, MSN, APR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 TAPCO LN
Mailing Address - Street 2:
Mailing Address - City:CLARKDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:86324-3415
Mailing Address - Country:US
Mailing Address - Phone:609-707-5291
Mailing Address - Fax:
Practice Address - Street 1:13175 E STATE ROUTE 169
Practice Address - Street 2:
Practice Address - City:DEWEY
Practice Address - State:AZ
Practice Address - Zip Code:86327-7416
Practice Address - Country:US
Practice Address - Phone:928-632-1155
Practice Address - Fax:928-632-5580
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00523800363LF0000X
AZAP9884363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ302368Medicaid