Healthcare Provider Details

I. General information

NPI: 1386557056
Provider Name (Legal Business Name): RAEGAN NOEL COLEMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 W AUGUSTA BLVD STE 1
CHICAGO IL
60642-4327
US

IV. Provider business mailing address

1203 W AUGUSTA BLVD STE 1
CHICAGO IL
60642-4327
US

V. Phone/Fax

Practice location:
  • Phone: 773-248-2255
  • Fax:
Mailing address:
  • Phone: 615-480-8572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085012469
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: