Provider Demographics
NPI:1043300767
Name:NORTHERN, CHRISTOPHER M (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:M
Last Name:NORTHERN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 STATION DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:
Practice Address - Street 1:360 STATION DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7978
Practice Address - Country:US
Practice Address - Phone:815-356-2330
Practice Address - Fax:815-477-9826
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1898-023207P00000X, 363A00000X
IL085002494363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43025400Medicaid
WI$$$$$$$$$004OtherBLUE SHIELD
WI007501473Medicare PIN
IL962341Medicare UPIN
WI013902905Medicare PIN
WI$$$$$$$$$004OtherBLUE SHIELD