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General NPI Number Information
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NPI Number | 1831779933
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Entity Type | Individual
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Provider Name | LAUREN AGOSTINACCHIO PA-C
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Gender | Female
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Dates
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Enumeration Date | 04/12/2021
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Last Update Date | 11/05/2024
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Provider Practice Location Address
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Address Line | 331 W SURF ST STE 700
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City | CHICAGO
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State | IL
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Zip | 60657-0083
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Country | US
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Telephone | 773-832-7443
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Fax | 773-295-4126
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Provider Business Mailing Address
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Address Line | 801 YORK ST
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City | MANITOWOC
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State | WI
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Zip | 54220-4630
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Country | US
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Telephone | 920-663-9008
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Fax | 920-684-1439
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085.008177
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License Number State | IL
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