Healthcare Provider Details

I. General information

NPI: 1083276695
Provider Name (Legal Business Name): KRISTINA MALIEJUS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE STE 3507
EVANSTON IL
60201-1778
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2868
  • Fax: 847-570-2827
Mailing address:
  • Phone: 847-982-6715
  • Fax: 847-982-3394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085007094
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.007094
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: