Provider Demographics
NPI:1104935899
Name:DZIEDZIC, ADAM ROBERT (PA-C)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:ROBERT
Last Name:DZIEDZIC
Suffix:
Gender:M
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 1:3410 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-3120
Mailing Address - Country:US
Mailing Address - Phone:224-610-8553
Mailing Address - Fax:
Practice Address - Street 1:3410 ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-3120
Practice Address - Country:US
Practice Address - Phone:224-610-8553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004025363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085004025OtherSTATE OF ILLINOIS
IL085004025OtherSTATE OF ILLINOIS