Provider Demographics
NPI:1083064299
Name:KLUCK, STEVEN (PA-C)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:KLUCK
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 1:4535 DRESSLER RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2545
Mailing Address - Country:US
Mailing Address - Phone:800-828-0898
Mailing Address - Fax:330-493-8677
Practice Address - Street 1:12935 GREGORY ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2428
Practice Address - Country:US
Practice Address - Phone:708-597-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-18
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005864363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant