Provider Demographics
NPI:1124386891
Name:CHARTYNOWICZ, AGNIESZKA (PA-C)
Entity type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:
Last Name:CHARTYNOWICZ
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 1:5826 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-1141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:680 N. LAKE SHORE DRIVE
Practice Address - Street 2:SUITE 1424
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-482-8484
Practice Address - Fax:312-482-9977
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002551363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty