Provider Demographics
NPI:1174696207
Name:NISAVIC, VERA (PA)
Entity type:Individual
Prefix:MS
First Name:VERA
Middle Name:
Last Name:NISAVIC
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST
Mailing Address - Street 2:STE 450
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2927
Mailing Address - Country:US
Mailing Address - Phone:312-988-1352
Mailing Address - Fax:
Practice Address - Street 1:676 N SAINT CLAIR ST
Practice Address - Street 2:STE 450
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-988-1352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP25260Medicare UPIN