Provider Demographics
NPI:1437115706
Name:WERNICK, FAYETTE POWERS (PA-C)
Entity Type:Individual
Prefix:
First Name:FAYETTE
Middle Name:POWERS
Last Name:WERNICK
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 1:1S450 SUMMIT AVE STE 165
Mailing Address - Street 2:
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-3952
Mailing Address - Country:US
Mailing Address - Phone:630-320-6871
Mailing Address - Fax:
Practice Address - Street 1:1S450 SUMMIT AVE STE 165
Practice Address - Street 2:
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181-3952
Practice Address - Country:US
Practice Address - Phone:630-320-6871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002200363A00000X
DCPA030489363AM0700X
IL085004332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA018600C25Medicare ID - Type Unspecified
VAQ59469Medicare UPIN