Provider Demographics
NPI:1053836783
Name:DOHERTY, BIANCA ALEXANDRIA (PA-C)
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:ALEXANDRIA
Last Name:DOHERTY
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 1:3909 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3741
Mailing Address - Country:US
Mailing Address - Phone:773-739-9200
Mailing Address - Fax:
Practice Address - Street 1:2073 N CLYBOURN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-4003
Practice Address - Country:US
Practice Address - Phone:773-665-4016
Practice Address - Fax:773-360-6200
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant