Basic Information
Provider Information | |||||||||
NPI: | 1013169135 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEDLACEK | ||||||||
FirstName: | MICHELLE | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WINE SEDLACEK | ||||||||
OtherFirstName: | MICHELLE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6320 W UNION HILLS DR STE 2600B | ||||||||
Address2: |   | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853081379 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029425600 | ||||||||
FaxNumber: | 6238256386 | ||||||||
Practice Location | |||||||||
Address1: | 6320 W UNION HILLS DR | ||||||||
Address2: | BLDG B #2600 | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853081096 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029425600 | ||||||||
FaxNumber: | 6238256386 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/21/2008 | ||||||||
LastUpdateDate: | 10/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 4884 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 646118 | 05 | AZ |   | MEDICAID |