Provider Demographics
NPI:1275965329
Name:GOSSETT, SARA BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:BETH
Last Name:GOSSETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:LENNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:550 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3186
Mailing Address - Country:US
Mailing Address - Phone:630-323-6116
Mailing Address - Fax:630-323-6169
Practice Address - Street 1:550 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3186
Practice Address - Country:US
Practice Address - Phone:630-323-6116
Practice Address - Fax:630-323-6169
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-004769363AS0400X
IL085004769363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085004769OtherILLINOIS PHYSICIAN ASSISTANT
ILML2954849OtherDEA
ILF400094550Medicare PIN