Provider Demographics
NPI:1306026935
Name:ZIDLICKY, SARA K (PA-C)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:K
Last Name:ZIDLICKY
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 1:290 SPRINGFIELD DR
Mailing Address - Street 2:SUITE 290
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2214
Mailing Address - Country:US
Mailing Address - Phone:630-893-9660
Mailing Address - Fax:630-893-9668
Practice Address - Street 1:290 SPRINGFIELD DR
Practice Address - Street 2:SUITE 290
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2214
Practice Address - Country:US
Practice Address - Phone:630-893-9660
Practice Address - Fax:630-893-9668
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003137363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003137OtherLICENSE
ILF400175927OtherMEDICARE PTAN (INDIVIDUAL)
IL920540OtherMEDICARE PTAN (GROUP)