Healthcare Provider Details

I. General information

NPI: 1053563643
Provider Name (Legal Business Name): NICHOLAS WARNECKE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 NE CRESCENT AVE
PEORIA IL
61606-1901
US

IV. Provider business mailing address

5100 RELIABLE PKWY
CHICAGO IL
60686-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-4670
  • Fax:
Mailing address:
  • Phone: 309-672-4809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085003358
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: