Provider Demographics
NPI:1104222389
Name:JAWOR, MICHELLE (PAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JAWOR
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:GALAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5080 KIMBERLY LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-1435
Mailing Address - Country:US
Mailing Address - Phone:708-253-3672
Mailing Address - Fax:
Practice Address - Street 1:21660 W FIELD PKWY DEER PARK
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:IL
Practice Address - Zip Code:60010
Practice Address - Country:US
Practice Address - Phone:888-803-3370
Practice Address - Fax:888-803-3331
Is Sole Proprietor?:No
Enumeration Date:2014-11-14
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005259363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01477409OtherRRMC
ILF400198820OtherLOCALITY 16
ILF400198821OtherLOCALITY 15
ILF400198821Medicare PIN
ILF400198821OtherLOCALITY 15
ILP01477409OtherRRMC