Healthcare Provider Details

I. General information

NPI: 1386099091
Provider Name (Legal Business Name): KRISTIN BEAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN GRAHAM PA-C

II. Dates (important events)

Enumeration Date: 05/01/2016
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W LAKE COOK RD SUITE 120
BUFFALO GROVE IL
60089-2089
US

IV. Provider business mailing address

600 W LAKE COOK RD SUITE 120
BUFFALO GROVE IL
60089-2089
US

V. Phone/Fax

Practice location:
  • Phone: 847-808-8884
  • Fax:
Mailing address:
  • Phone: 847-808-8884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085005824
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: