Healthcare Provider Details

I. General information

NPI: 1679300073
Provider Name (Legal Business Name): ANTHONY VICTOR PIASECKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S LAKE PARK AVE
HOBART IN
46342-6638
US

IV. Provider business mailing address

3612 E ENGEL DR
VALPARAISO IN
46383-8339
US

V. Phone/Fax

Practice location:
  • Phone: 219-942-0551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004621A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: