Healthcare Provider Details

I. General information

NPI: 1902629785
Provider Name (Legal Business Name): EVANGELINE ROSE ROBERTSHAW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 PFINGSTEN RD
GLENVIEW IL
60026-1301
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2040
  • Fax:
Mailing address:
  • Phone: 847-982-3172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085010895
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: