Provider Demographics
NPI:1679552509
Name:BEZDICEK, DONALD LYNN (PA-C)
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:LYNN
Last Name:BEZDICEK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1605 NORTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-8567
Mailing Address - Country:US
Mailing Address - Phone:651-206-3717
Mailing Address - Fax:
Practice Address - Street 1:7765 GALPIN BLVD
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-9463
Practice Address - Country:US
Practice Address - Phone:952-474-6623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2009-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9007363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN970002489Medicare UPIN