KRISTA DIANE NIEZWAAG Physician Assistant License verification

Business Entity

NOT RENEWED

License Type

Physician Assistant

Description

PHYSICIAN ASSISTANT CONTROLLED SUBSTANCE

License Number

38*****25

License Status

NOT RENEWED

Business

First Name

KRISTA

Middle

DIANE

Last Name

NIEZWAAG

Business Name

KRISTA DIANE NIEZWAAG

Original Issue Date

09/11/2014

Effective Date

03/12/2018

Expiration Date

03/01/2020

City

DIXON

State

Zip

61021

County

LEE

Delegated Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

11/24/2020