Provider Demographics
NPI:1386196590
Name:SISMOUR, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:SISMOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E HURON ST STE 16-738
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2908
Mailing Address - Country:US
Mailing Address - Phone:847-234-5600
Mailing Address - Fax:847-535-7203
Practice Address - Street 1:251 E HURON ST STE 16-738
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:847-234-5600
Practice Address - Fax:847-535-7203
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058746363A00000X, 363A00000X
IL085006711363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant