Provider Demographics
NPI:1649395930
Name:SHERRELL, LEON (PHYSICIANS ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:LEON
Middle Name:
Last Name:SHERRELL
Suffix:
Gender:M
Credentials:PHYSICIANS ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 E 47TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-4224
Mailing Address - Country:US
Mailing Address - Phone:773-624-4800
Mailing Address - Fax:
Practice Address - Street 1:654 E 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-4224
Practice Address - Country:US
Practice Address - Phone:773-624-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003211363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL138714ZAQPMedicare PIN
MD138714ZAQPMedicare PIN