Provider Demographics
NPI:1477254639
Name:ZACZYK, OLIVIA (PA-C)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:ZACZYK
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:PO BOX 779203
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-9203
Mailing Address - Country:US
Mailing Address - Phone:219-228-4200
Mailing Address - Fax:
Practice Address - Street 1:14785 W 101ST AVE STE 2A
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-3371
Practice Address - Country:US
Practice Address - Phone:219-228-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003960A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty