Provider Demographics
NPI:1477066777
Name:MUSASHE, JAKE (PA-C)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:MUSASHE
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 1:1725 W HARRISON ST STE 970
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3828
Mailing Address - Country:US
Mailing Address - Phone:312-563-3447
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 970
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3828
Practice Address - Country:US
Practice Address - Phone:312-563-3447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006426363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant