Provider Demographics
NPI:1295002715
Name:DIFFERDING, CHRISTOPHER JOHN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:JOHN
Last Name:DIFFERDING
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:600 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61362-1512
Mailing Address - Country:US
Mailing Address - Phone:815-664-2617
Mailing Address - Fax:815-664-5204
Practice Address - Street 1:600 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61362-1512
Practice Address - Country:US
Practice Address - Phone:815-664-2617
Practice Address - Fax:815-664-5204
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004245363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant