Healthcare Provider Details

I. General information

NPI: 1588926745
Provider Name (Legal Business Name): TINA F KNIGHT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 DEMPSTER ST SUITE 665
PARK RIDGE IL
60068-1186
US

IV. Provider business mailing address

1875 DEMPSTER ST SUITE 665
PARK RIDGE IL
60068-1186
US

V. Phone/Fax

Practice location:
  • Phone: 847-825-1590
  • Fax: 847-825-1604
Mailing address:
  • Phone: 847-825-1590
  • Fax: 847-825-1604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085.001612
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: