Individual
DANIEL M PROVENCHER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
911 N ELM ST, SUITE 128, HINSDALE, IL 60521-3640
(630) 789-2260
(630) 789-1584
Mailing address
911 N ELM ST, SUITE 128, HINSDALE, IL 60521-3640
(630) 789-2260
(630) 789-1584
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
085001850
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
362658747
FEDERAL TAX ID
IL
Enumeration date
08/20/2006
Last updated
01/12/2012
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