Provider Demographics
NPI:1265862874
Name:LUSTERIO, KORINNE MAE (PA-C)
Entity Type:Individual
Prefix:
First Name:KORINNE MAE
Middle Name:
Last Name:LUSTERIO
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 1:10400 HALIGUS RD
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-9553
Mailing Address - Country:US
Mailing Address - Phone:224-654-0100
Mailing Address - Fax:224-654-0105
Practice Address - Street 1:10400 HALIGUS RD
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-9553
Practice Address - Country:US
Practice Address - Phone:224-654-0100
Practice Address - Fax:224-654-0105
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
IL085009398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical