Provider Demographics
NPI:1306315817
Name:BALUKA, STEPHANIE (PA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BALUKA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1514
Mailing Address - Country:US
Mailing Address - Phone:708-701-3776
Mailing Address - Fax:
Practice Address - Street 1:6337 S WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-3707
Practice Address - Country:US
Practice Address - Phone:773-753-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-006816363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant