Healthcare Provider Details

I. General information

NPI: 1548543424
Provider Name (Legal Business Name): DEAN WILLIAM RODEMACK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 04/08/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W CAMAS AVE
FAIRFIELD ID
83327
US

IV. Provider business mailing address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

V. Phone/Fax

Practice location:
  • Phone: 208-764-2611
  • Fax: 208-933-4921
Mailing address:
  • Phone: 208-737-6718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60245393
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1020
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: