Provider Demographics
NPI:1235188533
Name:TOMCZAK, MARK A (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:TOMCZAK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18221 TORRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-2870
Mailing Address - Country:US
Mailing Address - Phone:708-895-9450
Mailing Address - Fax:708-895-9455
Practice Address - Street 1:18221 TORRENCE AVE
Practice Address - Street 2:SUITE 1B
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-2870
Practice Address - Country:US
Practice Address - Phone:708-895-9450
Practice Address - Fax:708-895-9455
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002567174400000X
IN28118620A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist