Healthcare Provider Details

I. General information

NPI: 1376099879
Provider Name (Legal Business Name): LIZANDRA ANZO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2016
Last Update Date: 03/07/2023
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4255 W 63RD ST
CHICAGO IL
60629-5041
US

IV. Provider business mailing address

4255 W 63RD ST
CHICAGO IL
60629-5041
US

V. Phone/Fax

Practice location:
  • Phone: 773-424-4048
  • Fax:
Mailing address:
  • Phone: 773-424-4048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-008930
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: