Provider Demographics
NPI:1275166191
Name:PETRUSHA, KALYNA (PA-C)
Entity Type:Individual
Prefix:
First Name:KALYNA
Middle Name:
Last Name:PETRUSHA
Suffix:
Gender:F
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 1:685 W WRIGHTWOOD AVE APT 2S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-7969
Mailing Address - Country:US
Mailing Address - Phone:248-703-4782
Mailing Address - Fax:
Practice Address - Street 1:3924 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2228
Practice Address - Country:US
Practice Address - Phone:773-276-2229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008427363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant