Provider Demographics
NPI:1467292565
Name:TRYBULA, PAWEL TOMASZ (PTA)
Entity type:Individual
Prefix:
First Name:PAWEL
Middle Name:TOMASZ
Last Name:TRYBULA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 W HUNTINGTON COMMONS RD APT 144
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-5255
Mailing Address - Country:US
Mailing Address - Phone:708-323-7752
Mailing Address - Fax:
Practice Address - Street 1:95 CARLETON AVE
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5500
Practice Address - Country:US
Practice Address - Phone:630-469-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009942225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant