Healthcare Provider Details

I. General information

NPI: 1104176262
Provider Name (Legal Business Name): ASHLEY L. OKIGAWA PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY L. LUSTGARTEN P. A.

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 N RANDALL RD STE 140
ELGIN IL
60123-9401
US

IV. Provider business mailing address

1710 N RANDALL RD STE 140
ELGIN IL
60123-9401
US

V. Phone/Fax

Practice location:
  • Phone: 224-293-1170
  • Fax: 847-289-0960
Mailing address:
  • Phone: 224-293-1170
  • Fax: 847-289-0960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004508
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: