Healthcare Provider Details

I. General information

NPI: 1932503802
Provider Name (Legal Business Name): FREDERIC LELAND ONDOVCHAK R.N., M.S.N., A.P.R.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13175 E STATE ROUTE 169
DEWEY AZ
86327-7416
US

IV. Provider business mailing address

601 TAPCO LN
CLARKDALE AZ
86324-3415
US

V. Phone/Fax

Practice location:
  • Phone: 928-632-1155
  • Fax: 928-632-5580
Mailing address:
  • Phone: 609-707-5291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00523800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP9884
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: