Healthcare Provider Details

I. General information

NPI: 1174907646
Provider Name (Legal Business Name): BRITTANY WACLAW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRITTANY SIMS

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N HALSTED ST STE 500
CHICAGO IL
60657-5194
US

IV. Provider business mailing address

2650 WARRENVILLE RD SUITE 280
DOWNERS GROVE IL
60515-1748
US

V. Phone/Fax

Practice location:
  • Phone: 773-477-4343
  • Fax:
Mailing address:
  • Phone: 630-324-7900
  • Fax: 630-929-8096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085005504
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: