Basic Information
| Provider Information | |||||||||
| NPI: | 1437115706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WERNICK | ||||||||
| FirstName: | FAYETTE | ||||||||
| MiddleName: | POWERS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1S450 SUMMIT AVE STE 165 | ||||||||
| Address2: | |||||||||
| City: | OAKBROOK TERRACE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601813952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303206871 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1S450 SUMMIT AVE STE 165 | ||||||||
| Address2: | |||||||||
| City: | OAKBROOK TERRACE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601813952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303206871 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110002200 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA030489 | DC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 085004332 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.