Provider Demographics
NPI:1952126203
Name:GLADSHTEYN, MARK ROMAN (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ROMAN
Last Name:GLADSHTEYN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE STE 1223
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1700
Mailing Address - Country:US
Mailing Address - Phone:847-982-3394
Mailing Address - Fax:
Practice Address - Street 1:880 W CENTRAL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2355
Practice Address - Country:US
Practice Address - Phone:847-255-0900
Practice Address - Fax:847-255-4344
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085010954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program