Provider Demographics
NPI:1962512293
Name:WALASZEK, DALE ROBERT (PA)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:ROBERT
Last Name:WALASZEK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 HOSPITAL PL
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-6999
Mailing Address - Country:US
Mailing Address - Phone:907-714-4502
Mailing Address - Fax:907-714-4696
Practice Address - Street 1:245 N BINKLEY ST
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7500
Practice Address - Country:US
Practice Address - Phone:907-714-4521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2005-0017363A00000X
AKPADA1183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1615861Medicaid
343608101Medicare ID - Type Unspecified