Provider Demographics
NPI:1376099879
Name:ANZO, LIZANDRA (PA)
Entity Type:Individual
Prefix:
First Name:LIZANDRA
Middle Name:
Last Name:ANZO
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 1:4255 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-5041
Mailing Address - Country:US
Mailing Address - Phone:773-424-4048
Mailing Address - Fax:
Practice Address - Street 1:4255 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5041
Practice Address - Country:US
Practice Address - Phone:773-424-4048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL171R00000X
IL085-008930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171R00000XOther Service ProvidersInterpreter
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-008930OtherSTATE MEDICAL LICENSE
IL385006802OtherSTATE CONTROLLED SUBSTANCE
IL385006802OtherSTATE CONTROLLED SUBSTANCE