Provider Demographics
NPI:1689943649
Name:WODYNSKI, JOHN CHARLES JR (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:WODYNSKI
Suffix:JR
Gender:M
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 1:1400 S. LAKE PARK AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6791
Mailing Address - Country:US
Mailing Address - Phone:219-947-6122
Mailing Address - Fax:219-947-6045
Practice Address - Street 1:1400 S LAKE PARK AVE STE 200-202
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6790
Practice Address - Country:US
Practice Address - Phone:219-947-6122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363AS0400X
IN10001589A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL892082Medicare PIN