=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396288346
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOANNA SZKWARLA PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2016
-----------------------------------------------------
Last Update Date | 10/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3943 W 31ST ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60623-4936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-523-8773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 269 GOODRIDGE TER
-----------------------------------------------------
City | ROSELLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60172-3536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-290-6939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 085006024
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------