Healthcare Provider Details

I. General information

NPI: 1902109267
Provider Name (Legal Business Name): BRETT WASSINK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST FL 13
CHICAGO IL
60611-3926
US

IV. Provider business mailing address

259 E ERIE ST FL 13
CHICAGO IL
60611-3926
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-6800
  • Fax: 312-926-6600
Mailing address:
  • Phone: 312-695-6800
  • Fax: 312-926-6600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number390200000X
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.004809
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: