Provider Demographics
NPI:1548543424
Name:RODEMACK, DEAN WILLIAM (PA-C)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:WILLIAM
Last Name:RODEMACK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-737-6718
Mailing Address - Fax:
Practice Address - Street 1:401 W CAMAS AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:ID
Practice Address - Zip Code:83327
Practice Address - Country:US
Practice Address - Phone:208-764-2611
Practice Address - Fax:208-933-4921
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60245393363AS0400X
IDPA-1020363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA158543424Medicaid
WA0285610OtherLABOR & INDUSTRIES
WA0285610OtherLABOR & INDUSTRIES