Healthcare Provider Details

I. General information

NPI: 1790305704
Provider Name (Legal Business Name): EVAN TKACZYK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 01/31/2021
Certification Date: 01/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2322 W PETERSON AVE.
CHICAGO IL
60659-3120
US

IV. Provider business mailing address

87 S 2ND AVE
LOMBARD IL
60148
US

V. Phone/Fax

Practice location:
  • Phone: 800-325-1812
  • Fax:
Mailing address:
  • Phone: 630-408-6687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: