Healthcare Provider Details

I. General information

NPI: 1982583233
Provider Name (Legal Business Name): JASON WIECZOREK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2025
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9291 MEDICAL PLAZA DR
NORTH CHARLESTON SC
29406-9126
US

IV. Provider business mailing address

6800 W ARDMORE AVE
CHICAGO IL
60631-3111
US

V. Phone/Fax

Practice location:
  • Phone: 843-764-1730
  • Fax:
Mailing address:
  • Phone: 773-677-7066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6155
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: