Provider Demographics
NPI:1467541227
Name:THARNSTROM, JOHN (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:THARNSTROM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-946-9200
Mailing Address - Fax:
Practice Address - Street 1:808 RICKERT DR STE 103
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-0908
Practice Address - Country:US
Practice Address - Phone:331-551-5854
Practice Address - Fax:630-348-3098
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002044207P00000X
TXPA09915363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant