Provider Demographics
NPI:1417473141
Name:DYNKOWSKI, MICHAEL (APN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DYNKOWSKI
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 W BERENICE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2720
Mailing Address - Country:US
Mailing Address - Phone:785-218-1635
Mailing Address - Fax:
Practice Address - Street 1:850 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3077
Practice Address - Country:US
Practice Address - Phone:773-525-6780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016027363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily