Provider Demographics
NPI:1003994104
Name:BANDUSCH HARRIS, KAREN JANE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:JANE
Last Name:BANDUSCH HARRIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 LISMORE LANE
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761
Mailing Address - Country:US
Mailing Address - Phone:309-888-9816
Mailing Address - Fax:
Practice Address - Street 1:405 KAYS DRIVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-862-0064
Practice Address - Fax:309-862-1542
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085 000712363A00000X
IL085-000712363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
084278OtherHEALTH ALLIANCE
588330OtherOSF HEALTH PLAN CP
5723204OtherBCBS
IL588330Medicaid
CK5970OtherRR MEDIC