Provider Demographics
NPI:1649623679
Name:DZIAGWA, MICHAEL JOSEPH I (NP-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:DZIAGWA
Suffix:I
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 KOLTER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3570
Mailing Address - Country:US
Mailing Address - Phone:724-357-7196
Mailing Address - Fax:724-357-7279
Practice Address - Street 1:879 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3629
Practice Address - Country:US
Practice Address - Phone:724-357-8198
Practice Address - Fax:724-357-8202
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAF0716288363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily