Provider Demographics
NPI:1043595465
Name:WOOTEN, DALE A JR (CCP)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:A
Last Name:WOOTEN
Suffix:JR
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27664
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85285-7664
Mailing Address - Country:US
Mailing Address - Phone:480-777-0607
Mailing Address - Fax:480-777-1345
Practice Address - Street 1:312 E HOUSTON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8218
Practice Address - Country:US
Practice Address - Phone:480-777-0607
Practice Address - Fax:480-777-1345
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist