Provider Demographics
NPI:1912136581
Name:OFTEDAHL, DUANE C (PA-C)
Entity Type:Individual
Prefix:
First Name:DUANE
Middle Name:C
Last Name:OFTEDAHL
Suffix:
Gender:M
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 1:1700 W STOUT ST
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-5000
Mailing Address - Country:US
Mailing Address - Phone:715-236-8365
Mailing Address - Fax:715-236-8302
Practice Address - Street 1:1700 W STOUT ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-5000
Practice Address - Country:US
Practice Address - Phone:715-236-8365
Practice Address - Fax:715-236-8302
Is Sole Proprietor?:No
Enumeration Date:2009-07-04
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10591363A00000X
WAPA60497499363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant