Basic Information
| Provider Information | |||||||||
| NPI: | 1962512293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALASZEK | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 HOSPITAL PL | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996696999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077144502 | ||||||||
| FaxNumber: | 9077144696 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 N BINKLEY ST | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996697500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077144521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2005-0017 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PADA1183 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1615861 | 05 | AK | MEDICAID |