Healthcare Provider Details

I. General information

NPI: 1538457759
Provider Name (Legal Business Name): KINZIE G. SHARP PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2073 N CLYBOURN AVE
CHICAGO IL
60614-4003
US

IV. Provider business mailing address

2073 N CLYBOURN AVE
CHICAGO IL
60614-4003
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-4106
  • Fax: 773-360-6200
Mailing address:
  • Phone: 773-665-4016
  • Fax: 773-960-6200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004073
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: