Provider Demographics
NPI:1013169135
Name:SEDLACEK, MICHELLE W (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:W
Last Name:SEDLACEK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:WINE SEDLACEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6320 W UNION HILLS DR STE 2600B
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1379
Mailing Address - Country:US
Mailing Address - Phone:602-942-5600
Mailing Address - Fax:623-825-6386
Practice Address - Street 1:6320 W UNION HILLS DR
Practice Address - Street 2:BLDG B #2600
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1096
Practice Address - Country:US
Practice Address - Phone:602-942-5600
Practice Address - Fax:623-825-6386
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4884363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ646118Medicaid
KS110935021Medicare PIN
AZ646118Medicaid