Healthcare Provider Details

I. General information

NPI: 1912459058
Provider Name (Legal Business Name): PATRICK STAGG P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST STE 13-205
CHICAGO IL
60611-2987
US

IV. Provider business mailing address

1 WESTBROOK CORPORATE CTR STE 240
WESTCHESTER IL
60154-5745
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-8143
  • Fax: 312-695-4075
Mailing address:
  • Phone: 219-769-8340
  • Fax: 219-769-8341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002143A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.006604
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: