Provider Demographics
NPI:1659761567
Name:EVERTSEN, LISA (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:EVERTSEN
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 1:840 BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-4410
Mailing Address - Country:US
Mailing Address - Phone:847-494-5566
Mailing Address - Fax:847-364-5566
Practice Address - Street 1:1225 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160
Practice Address - Country:US
Practice Address - Phone:708-681-3000
Practice Address - Fax:708-938-7179
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant