Healthcare Provider Details

I. General information

NPI: 1720322654
Provider Name (Legal Business Name): TARA COLE NIKODEM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1948 THREE FARMS AVE
NAPERVILLE IL
60540-1105
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 630-355-5633
  • Fax:
Mailing address:
  • Phone: 847-982-3363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085004540
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.004540
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: