DANIEL MARK PROVENCHER Physician Assistant License verification

Business Entity

NOT RENEWED

License Type

Physician Assistant

Description

PHYSICIAN ASSISTANT CONTROLLED SUBSTANCE

License Number

38*****56

License Status

NOT RENEWED

Business

First Name

DANIEL

Middle

MARK

Last Name

PROVENCHER

Business Name

DANIEL MARK PROVENCHER

Original Issue Date

11/22/2002

Effective Date

12/29/2011

Expiration Date

03/01/2014

City

HINSDALE

State

Zip

60521

County

DUPAGE

Ever Disciplined

LastModifiedDate

12/19/2013