Provider Demographics
NPI:1629292917
Name:JANICIJEVIC, ZLATA (PA)
Entity Type:Individual
Prefix:
First Name:ZLATA
Middle Name:
Last Name:JANICIJEVIC
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2231 W MAYPOLE
Mailing Address - Street 2:UNIT 302
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2697
Mailing Address - Country:US
Mailing Address - Phone:773-206-2447
Mailing Address - Fax:
Practice Address - Street 1:4646 N MARINE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5759
Practice Address - Country:US
Practice Address - Phone:773-564-5529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ16339Medicare UPIN