Provider Demographics
NPI:1063070126
Name:PTACK, MICHAEL ALEXANDER (ND)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALEXANDER
Last Name:PTACK
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14145 N 92ND ST UNIT 1159
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-3713
Mailing Address - Country:US
Mailing Address - Phone:312-213-4544
Mailing Address - Fax:
Practice Address - Street 1:14145 N 92ND ST UNIT 1159
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-3713
Practice Address - Country:US
Practice Address - Phone:312-213-4544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18-1719175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath