Provider Demographics
NPI:1861008443
Name:WOJTYCZKA, JUSTYNA (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTYNA
Middle Name:
Last Name:WOJTYCZKA
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 1:518 W LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:353 E BURLINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2082
Practice Address - Country:US
Practice Address - Phone:708-442-0221
Practice Address - Fax:708-442-5670
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-19
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363AS0400X
IL085008824363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty