Healthcare Provider Details

I. General information

NPI: 1811510506
Provider Name (Legal Business Name): KRISTA WUNSCH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 GRAND AVE STE A
WAUKEGAN IL
60085-3676
US

IV. Provider business mailing address

1616 GRAND AVE STE A
WAUKEGAN IL
60085-3676
US

V. Phone/Fax

Practice location:
  • Phone: 847-249-1733
  • Fax: 847-782-4515
Mailing address:
  • Phone: 847-249-1733
  • Fax: 847-782-4515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008391
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: