Provider Demographics
NPI:1770147092
Name:MIZERA, STEPHEN (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:MIZERA
Suffix:
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 1:396 REMINGTON BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4309
Mailing Address - Country:US
Mailing Address - Phone:630-759-1248
Mailing Address - Fax:
Practice Address - Street 1:396 REMINGTON BLVD STE 130
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4309
Practice Address - Country:US
Practice Address - Phone:630-759-1248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant