Provider Demographics
NPI:1194887240
Name:WANK, MICHEAL D (PA-C)
Entity type:Individual
Prefix:
First Name:MICHEAL
Middle Name:D
Last Name:WANK
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 1:2111 MIDLANDS CT
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3125
Mailing Address - Country:US
Mailing Address - Phone:815-758-0000
Mailing Address - Fax:815-756-7130
Practice Address - Street 1:2111 MIDLANDS CT
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3125
Practice Address - Country:US
Practice Address - Phone:815-758-0000
Practice Address - Fax:815-756-7130
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000909A363A00000X
IL085-003083363AS0400X
IL085003083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000513306OtherANTHEM
IL035958001OtherDMERC
IN000000513306OtherANTHEM
IL035958001OtherDMERC