Provider Demographics
NPI:1639321482
Name:WHARTON, STACIE (PA)
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:
Last Name:WHARTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 REMINGTON BLVD
Mailing Address - Street 2:UNIT 205
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-5827
Mailing Address - Country:US
Mailing Address - Phone:630-226-1130
Mailing Address - Fax:360-226-1134
Practice Address - Street 1:431 WEST LIBERTY STREET
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084
Practice Address - Country:US
Practice Address - Phone:847-526-2151
Practice Address - Fax:815-678-4184
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003268363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003268OtherSTATE OF ILLINOIS LICENSE