Healthcare Provider Details

I. General information

NPI: 1689943649
Provider Name (Legal Business Name): JOHN CHARLES WODYNSKI JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S LAKE PARK AVE STE 200-202
HOBART IN
46342-6790
US

IV. Provider business mailing address

1400 S. LAKE PARK AVENUE SUITE 200
HOBART IN
46342-6791
US

V. Phone/Fax

Practice location:
  • Phone: 219-947-6122
  • Fax:
Mailing address:
  • Phone: 219-947-6122
  • Fax: 219-947-6045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001589A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: