| Doctor Name: | DANIEL M PROVENCHER |
| NPI Number: | 1053426965 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA-C |
| License Number: | 085001850 |
| Business Practice Address: | 911 N Elm St Suite 128 Hinsdale, IL - 605213640 |
| Business Phone Number: | 6307892260 |
| Business Fax Number: | 6307891584 |
| Mailing Address: | 911 N Elm St, Suite 128 HINSDALE |
| State: | IL |
| Postal Code: | 605213640 |
| Phone Number: | 6307892260 |
| Fax Number: | 6307891584 |
| NPI Enumeration Date: | 08/20/2006 |
| NPI Last Update Date: | 01/12/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | 085001850 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |