Provider Demographics
NPI:1053427831
Name:MICKIEWICZ, VIOLETTA (PA-C)
Entity type:Individual
Prefix:
First Name:VIOLETTA
Middle Name:
Last Name:MICKIEWICZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 WINCHESTER
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640
Mailing Address - Country:US
Mailing Address - Phone:773-250-0500
Mailing Address - Fax:773-250-0497
Practice Address - Street 1:4501 N WINCHESTER AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5265
Practice Address - Country:US
Practice Address - Phone:773-250-0500
Practice Address - Fax:773-250-0497
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical