Healthcare Provider Details

I. General information

NPI: 1255218483
Provider Name (Legal Business Name): LAUREN MARIE PINGSTERHAUS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GOOD SAMARITAN WAY
MOUNT VERNON IL
62864-2402
US

IV. Provider business mailing address

1101 E GRAND AVE APT D12
CARBONDALE IL
62901-3531
US

V. Phone/Fax

Practice location:
  • Phone: 618-899-4600
  • Fax:
Mailing address:
  • Phone: 618-541-7430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: