Healthcare Provider Details

I. General information

NPI: 1730841412
Provider Name (Legal Business Name): CHRISTOPHER MICHAEL MYSLICKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2021
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 SPINDER DR
EAST PEORIA IL
61611-0016
US

IV. Provider business mailing address

2000 UNIVERSITY AVE
DUBUQUE IA
52001-5099
US

V. Phone/Fax

Practice location:
  • Phone: 309-308-5100
  • Fax:
Mailing address:
  • Phone: 630-865-6533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.009531
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: