Provider Demographics
NPI:1316385875
Name:CACERES, VICTOR THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:THOMAS
Last Name:CACERES
Suffix:
Gender:M
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 1:1900 W POLK ST
Mailing Address - Street 2:10TH FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3723
Mailing Address - Country:US
Mailing Address - Phone:920-318-9552
Mailing Address - Fax:
Practice Address - Street 1:1900 W POLK ST
Practice Address - Street 2:10TH FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3723
Practice Address - Country:US
Practice Address - Phone:312-091-1864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60838852363A00000X
WI1108842363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant