Provider Demographics
NPI:1437247996
Name:VESPA, SALLY A (PA-C)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:VESPA
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 1:1301 S KOKE MILL RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-9252
Mailing Address - Country:US
Mailing Address - Phone:217-547-9100
Mailing Address - Fax:217-547-9236
Practice Address - Street 1:1301 S KOKE MILL RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-9252
Practice Address - Country:US
Practice Address - Phone:217-547-9100
Practice Address - Fax:217-547-9236
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000888363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S97296Medicare UPIN
K24467Medicare ID - Type Unspecified