Provider Demographics
NPI:1437671435
Name:WLOSEK, KRZYSZTOF (APN)
Entity Type:Individual
Prefix:
First Name:KRZYSZTOF
Middle Name:
Last Name:WLOSEK
Suffix:
Gender:M
Credentials:APN
Other - Prefix:MR
Other - First Name:KRIS
Other - Middle Name:
Other - Last Name:WLOSEK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APN
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-383-3087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015995363L00000X
IL209.015995363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily