Provider Demographics
NPI:1629025978
Name:MAZUR, LAUREN E (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:E
Last Name:MAZUR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:E
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1 WESTBROOK CORPORATE CTR
Mailing Address - Street 2:#240
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 W HARRISON ST
Practice Address - Street 2:STE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-243-4244
Practice Address - Fax:312-942-1517
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002391363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209119OtherMEDICARE PTAN LOCALITY 16
IL209118OtherMEDICARE PTAN LOCALITY 15
ILK16177Medicare PIN
IL209118OtherMEDICARE PTAN LOCALITY 15
IL209119OtherMEDICARE PTAN LOCALITY 16