Provider Demographics
NPI:1275574469
Name:AMUNDSON, BRIAN D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:D
Last Name:AMUNDSON
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 1:550 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3186
Mailing Address - Country:US
Mailing Address - Phone:630-323-6116
Mailing Address - Fax:630-323-6169
Practice Address - Street 1:550 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3186
Practice Address - Country:US
Practice Address - Phone:630-323-6116
Practice Address - Fax:630-323-6169
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002379363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP95794Medicare UPIN
ILK15544Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER