Provider Demographics
NPI:1841674769
Name:DAZA, JENNIFER ANN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:DAZA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 86TH ST
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-4204
Mailing Address - Country:US
Mailing Address - Phone:515-276-3406
Mailing Address - Fax:515-278-2377
Practice Address - Street 1:2901 86TH ST
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-4204
Practice Address - Country:US
Practice Address - Phone:515-276-3406
Practice Address - Fax:515-278-2377
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA078992363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA078992OtherIOWA LICENSE