Healthcare Provider Details

I. General information

NPI: 1124509773
Provider Name (Legal Business Name): SARA BURKE CONNOLLY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST STE 5-704
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

251 E HURON ST STE 5-704
CHICAGO IL
60611-2908
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-0061
  • Fax: 312-926-8341
Mailing address:
  • Phone: 312-695-0061
  • Fax: 312-926-8341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2018034962
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006538
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: