Provider Demographics
NPI:1598026536
Name:OBERLIES, CANDICE (PA-C)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:OBERLIES
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 1:1010 LAKE ST STE 500
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1135
Mailing Address - Country:US
Mailing Address - Phone:708-524-8600
Mailing Address - Fax:708-524-8147
Practice Address - Street 1:1010 LAKE ST STE 500
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1135
Practice Address - Country:US
Practice Address - Phone:708-524-8600
Practice Address - Fax:708-524-8147
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400136774Medicare PIN