Provider Demographics
NPI:1366622672
Name:DYBALA, ANDREW DONALD (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:DONALD
Last Name:DYBALA
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 1:1500 S MILL AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-6699
Mailing Address - Country:US
Mailing Address - Phone:480-784-5533
Mailing Address - Fax:
Practice Address - Street 1:1500 S MILL AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-6699
Practice Address - Country:US
Practice Address - Phone:480-784-5533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3727363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ280968Medicaid
AZZ118861Medicare PIN