Provider Demographics
NPI:1275200149
Name:PROTAZIUK, DAVID (FNP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PROTAZIUK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 N CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1651
Mailing Address - Country:US
Mailing Address - Phone:708-669-7671
Mailing Address - Fax:
Practice Address - Street 1:4211 N CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1651
Practice Address - Country:US
Practice Address - Phone:312-481-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2022-06-14
Deactivation Date:2022-03-09
Deactivation Code:
Reactivation Date:2022-04-18
Provider Licenses
StateLicense IDTaxonomies
IL209023900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily