Provider Demographics
NPI:1568761591
Name:BOBAN, ANNETTE FACINELLI (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:FACINELLI
Last Name:BOBAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:ELAINE
Other - Last Name:FACINELLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60064-0610
Mailing Address - Country:US
Mailing Address - Phone:847-578-8767
Mailing Address - Fax:847-578-8671
Practice Address - Street 1:3471 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3090
Practice Address - Country:US
Practice Address - Phone:847-473-4357
Practice Address - Fax:847-578-3269
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000395363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant