Provider Demographics
NPI:1609818996
Name:TYMOUCH, LANA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LANA
Middle Name:
Last Name:TYMOUCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:SVITLANA
Other - Middle Name:
Other - Last Name:TYMOUCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:850 S WABASH AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3641
Mailing Address - Country:US
Mailing Address - Phone:312-583-1066
Mailing Address - Fax:312-583-1897
Practice Address - Street 1:850 S WABASH AVE
Practice Address - Street 2:STE 301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3641
Practice Address - Country:US
Practice Address - Phone:312-583-1066
Practice Address - Fax:312-583-1897
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001905363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP85306Medicare UPIN