Individual
DR. DWAYNE MICHAEL ST JACQUES
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
15215 S 48TH ST, SUITE 110, PHOENIX, AZ 85044-9142
(480) 783-8964
(480) 783-8967
Mailing address
15215 S 48TH ST, SUITE 110, PHOENIX, AZ 85044-9142
(480) 783-8964
(480) 783-8967
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
AZ24143
AZ
2080A0000X
Pediatric Adolescent Medicine Physician
24143
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
424052
—
AZ
Enumeration date
02/14/2006
Last updated
01/22/2019
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