Provider Demographics
NPI:1942457734
Name:MACZKO, REBECCA SUE (PA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:SUE
Last Name:MACZKO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:SUE
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:27650 FERRY RD
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3845
Mailing Address - Country:US
Mailing Address - Phone:630-225-2345
Mailing Address - Fax:
Practice Address - Street 1:27650 FERRY RD
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3845
Practice Address - Country:US
Practice Address - Phone:630-225-2345
Practice Address - Fax:630-225-2399
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003248363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01279235OtherRR MEDICARE
ILP01279235OtherRR MEDICARE