Healthcare Provider Details

I. General information

NPI: 1942837976
Provider Name (Legal Business Name): DEVON ANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 GROSS POINT RD STE 1200
SKOKIE IL
60076-1214
US

IV. Provider business mailing address

9600 GROSS POINT RD STE 1200
SKOKIE IL
60076-1214
US

V. Phone/Fax

Practice location:
  • Phone: 847-866-7846
  • Fax:
Mailing address:
  • Phone: 847-866-7846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number101927
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: