Healthcare Provider Details

I. General information

NPI: 1932809423
Provider Name (Legal Business Name): ELLIE VRAA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 W OGDEN AVE
CHICAGO IL
60623-2460
US

IV. Provider business mailing address

3860 W OGDEN AVE
CHICAGO IL
60623-2460
US

V. Phone/Fax

Practice location:
  • Phone: 872-588-3000
  • Fax:
Mailing address:
  • Phone: 872-588-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009604
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: