Healthcare Provider Details

I. General information

NPI: 1528516762
Provider Name (Legal Business Name): LISA M DAUL RUBEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2016
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST STE 1600
CHICAGO IL
60611-3111
US

IV. Provider business mailing address

259 E ERIE ST STE 1600
CHICAGO IL
60611-3111
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-6868
  • Fax:
Mailing address:
  • Phone: 312-695-6868
  • Fax: 312-695-2729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006020
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: